Inspection·August 25, 2022

F 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9/1/21- Physical aggression towards another resident. He was hit with a spoon and this resident punched her in the eye 12/18/21- Behavior of stacking dressers on top each other, picking up chairs and threating to throw them. 1/25/22- physical behavior- hit another resident in back. 6/25/22-physical aggression towards another resident. 07/13/2022 - Physical aggression toward another Resident. 07/13/2022 - Physical aggression toward of resident rejecting care and being agitated. Interventions: Resident placed on 1:1 supervision with family member until transfer to behavioral hospital for further evaluation. Date Initiated: 7/13/2022 - Resident placed on 1:1 supervision with family member until transfer to behavioral hospital for further evaluation. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of CR#1's nurse's documentation, reflect in parts - 7/22/2022 12:10 AM: The SW spoke with the hospital about discharge concerns. CR #1 was physically aggressive with multiple residents and staff. At this time, it was not safe for him to return to the secured unit for the safety of all residents and staff . Record review of Social Worker's note dated 07/22/22 reflect in part-The SW also spoke with the RP about safety concerns. The RP was informed that due to CR #1's aggressive behavior, the IDT has recommended that CR #1 should not return to the secured unit and a long-term Geri-psych unit may be best for his current needs. The RP was working with the hospital to find long term placement for CR #1. 7 /13/2022 9:18PM: Family member at the resident's' side. No aggression was noted at this time. 7 /14/2022 12:25 AM EMS arrived at facility to transport the resident to local psychiatric hospital, resident was transported via stretcher. The DON/Administrator/family member were notified about transfer. In an interview with the DON on 08/23/22 at 1:28 PM, she said, she started working at the facility in February of 2022. She said CR #1 had become physically aggressive with other residents and the frequency of incidents was increasing. She said CR #1 was sent out twice to a local psychiatric hospital in July of 2022, and the 2nd time CR #1 was not allowed to return to the facility due to the safety of other residents During an interview with the facility Administrator and the DON on 08/25/22 at 1:30PM, the Administrator said the facility did not re-admit CR #1 back, due to the safety of other residents at the facility. The Administrator said there was no policy on permitting residents back into the facility. The DON said CR #1 was not assessed and re-evaluated, but he was directed and re-directed according to his care plan. Record review of the facility's admission packet did not address readmitting resident back to the facility after admission to psychiatric hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521 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 - Some 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 observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate dispensing and administration of all drugs or biologicals) to meet the needs of each resident and ensure expired and discontinued drugs or biologicals were not available for use in 1of 2 nurses med cart (LVN B) and one of one medication room, reviewed for pharmacy services. The facility failed to ensure an opened Lidocaine 1% multi-dose vial partially used, and without an open date or resident name, was removed from the nurse's med cart (LVN B). The facility failed to ensure discontinued meds were not stored next to mixed supplies of foley catheter, wound care supplies, suture removal and foley anchor kits, and a 30 pack of beer cans, in the one Med Rm. The facility failed to ensure the intravenous (IV) emergency kit was sealed and secured, and the Med Room sink without rust stains and clean. These failures could place all residents at risk of not receiving the intended therapeutic benefit of their medications, and the potential to facilitate drug diversions. Findings included: During observation on [DATE] at 1:35 p.m. of LVN B's med cart revealed an opened Lidocaine 1% multi-dose injectable vial, partially used and without an open date. Observed no resident name on the accessed multi-dose vial. During observation on [DATE] at 1:45 p.m. of the Med Room revealed 2 medium sized containers of discontinued meds were stored next to a 30 pack beer cans and 3 medium sized cardboard boxes with mixed supplies of suture removal kits, wound care supplies, foley catheter and foley anchor kits. Further observation on [DATE] at 1:45 p.m. of the Med Room revealed an unsealed IV emergency-kit and an unsealed clear plastic container labeled emergency-kit with contents of a box of insect wipes and 5 syringes. The Med room sink was observed to have rust stains and was dirty with dust. During an interview on [DATE] at 1:55 p.m. LVN B confirmed the lidocaine 1% multidose vial was opened and accessed, but she did not know which resident it was used on. She stated the multidose vial was partially used, with no open date or resident name on it. LVN B stated that nurses were responsible to dispose of unlabeled, opened multidose vials and to ensure meds labeled properly. She stated she knew it should have been removed from the med cart. During an interview on [DATE] at 1:55 p.m. LVN B stated that the unsealed clear plastic container was not an E-kit although labeled emergency kit. She stated however the IV emergency-kit should have been sealed and she knew the process. She stated that we have the NYXIS (automated dispensing) for meds, which required a password from nurses. During an interview on [DATE] at 2:00 pm LVN C stated the 30 pack of beer cans found was ordered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521 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 - Some for a resident, therefore it was in the Med room. She stated she would remove the plastic container labeled emergency kit, which was not an E-kit. She stated that she did not know who placed a box of insect wipes, with the syringes on it, and she will remove the excessive boxes with mixed supllies next to discontinued meds. During an interview on [DATE] at 10:00 a.m. the ADON stated the opened Lidocaine 1% multidose vial could be from a discharged resident on completed antibiotic, but she did not know which resident it was used on. The ADON stated an opened or accessed multidose vial should have an open date and must have a resident name if entered and used in resident's room. She stated she would in-service staff including topics on E-kit proper procedures and notifying the pharmacy. During an interview on [DATE] at 2:30 p.m. ADON stated CS staff was in the process of removing the excessive boxes in the Med room. She stated the CS staff started re-organizing the Med room and labeling the shelves. She stated we have not used the sink, maintenance cleaned the rusts around the sink and were working on replacing it. During an interview on [DATE] at 3:00 p.m. the Administrator stated moving forward we would follow up all issues on meds and the Medication room with QAPI. Record review of facility provided policy titled, Storage of Medications dated [DATE] reflected in part, medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medication storage areas are kept clean, well lit, and free of clutter and extreme temperatures. Once opened, these products will be acceptable to use until the manufacturer's expiration date is reached unless the medication is in a multi-dose injectable vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521 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 - Few 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 residents who use antipsychotic drugs receive gradual dose reduction, and behavioral interventions, unless clinically necessary contraindicated, in an effort to discontinue these drugs for 1 of 14 residents ( Residents #15) reviewed for unnecessary psychotropic meds. The facility administered an antipsychotic medication without adequate indications for use and did not obtain a rationale for continuing the concurrent use of the psychotropic for Residents #15. This failure could place any resident on psychoactive medications and those with a diagnosis of dementia administered with antipsychotic meds, at risk for receiving unnecessary drugs and adverse reactions. Findings included: Record review of Resident #15's clinical record revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance, anxiety disorder, insomnia, conductive hearing loss, bilateral and HTN. Record review of Resident #15's quarterly MDS assessment, dated 6/10/22 revealed Active Diagnoses did not have a check by the disorders Depression, Bipolar, Psychotic disorder or Schizophrenia. Mood interview with total severity score=0. No hallucination or delusion. Resident with severely impaired cognition. He required 1 staff supervision most ADLs. Further noted he sometimes understood, and sometimes understands. Record review of undated Resident #15's care plan, revealed he had impaired thought processes related to dementia, and taking psychotropic meds related to anxiety. The resident was at risk of experiencing adverse consequences and to monitor for side effects and effectiveness from psychotropic drug use. Ask yes/no questions in order to determine resident's needs. Anticipate and meet needs. Record review of Resident #15's Physician's Orders dated August 2022, revealed give Risperdal (Risperidone) 1 mg 1 tab po at bedtime, for severe mood disorder, start date 8/02/22.; and Risperdal (Risperidone) 0.5 mg tab po q day, for severe mood disorder, start date 8/02/22. Further noted, reflected dx: Unspecified mood affective disorder. Record review of Resident #15's MAR dated August 2022 revealed Resident received Risperdal (Risperidone) 1 mg 1 tab po at bedtime, for severe mood disorder, start date 8/02/22 and Risperdal (Risperidone) 0.5 mg tab po q day, for severe mood disorder, start date 8/02/22. Further note reflected dx: Unspecified mood affective disorder; Antipsychotic/ Antimanic. Record review of Resident #15's, Behavior Monitoring, dated August 2022, revealed no behaviors noted. Monitoring for behaviors of yelling, screaming, cursing, hallucinations. dx severe mood disorder with psychotic symptoms. Episodes: zero. No documentation of hallucinations or delusions. During interview on 8/23/22 at 2:00 p.m. CNA E stated that Resident #15 was pleasantly confused and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521 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 - Few redirectable most of the time. She stated she had not seen him with any verbal aggression but was a sundowner (state of confusion occurring in the late p.m). During interview on 8/23/22 at 2:30 p.m. the DON stated Resident #15 had an attempted elopement behavior, a day after he tested Covid-19 (+) 7/23/22 and which could be related to increased confusion with the room change. She further stated the ADON was responsible for overseeing psych meds and ensuring with appropriate indication for its use or proper dx. During interview on 8/25/22 at 10:00 a.m. the ADON stated Resident #15 received the anti-psychotic Risperdal for dx of unspecified mood affective disorder; Antipsychotic/ Antimanic. She stated she would re-educate the staff, that antipsychotic/antimanic was a medication classification and not the dx. The ADON stated she was responsible to follow-up on psychotropic meds, and she would continue monitoring them. The ADON stated the new psychological services or group just started on 8/01/22, and psych consult was called yesterday 8/24/22, to review Resident #15's psychotropic meds. During interview on 8/25/22 at 2:30 p.m. LVN C stated the psychiatry NP consult was called and the NP ordered today to discontinue Resident #15's Risperdal and would be starting him on Trileptal (mood stabilizer) medication for dx. of mood disorder. In an interview on 8/25/22 at 3:00 p.m. the Administrator stated they would follow-up all issues on medications with QAPI. Record review of the facility's policy titled, Antipsychotic Medication Use for Residents with Dementia dated 11/01/219 reflected in part, Residents receiving antipsychotic meds for [NAME] fide psychiatry dx will be evaluated regularly according to regulation. Facility will have processes in place to monitor specific behavioral symptoms and are encouraged to use tools that enable the facility to identify changes to the specific behaviors overtime as the person with Dementia progresses in his/her disability and or situation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for 4 (Residents #1, #2, #46, #49) out of 4 residents reviewed for infection control. Residents Affected - Some In that: 1. MA B failed to sanitize blood pressure machine being used for multiple residents. 2. Facility failed to ensure Resident #46's nephrostomy catheter bag was kept in a safe and sanitary place away from the trash. These failures could place residents at risk of cross contamination and infection. Findings include: 1. Resident #46 Review of Resident #46's face sheet reflected the resident was a [AGE] year old male admitted to the facility on [DATE]. Resident' #46'sdiagnoses included Acute cystitis, obstructive and reflux uropathy, retention of urine, left buttock wound, immobility syndrome, and multiple sclerosis. On 08/23/2022 at 10:07 AM the surveyor observed Resident #46 in bed in his room. He had a nephrostomy with catheter bag. The Surveyor observed the catheter bag was placed in the trash container where there was trash. Resident #46 stated he dropped the catheter bag in the trash can because it was leaking. De stated he did not want it to mess up his bed. Review of Resident #46's skin assessment reflected he currently had a hip wound which had been previously infected. On 08/23/2022 at 10:10 AM the Surveyor called the nurse on the floor LVN C who stated the resident had been told not to place the bag in the trash but he refused and still wanted to do it his own way. She said the resident would always drop the catheter in the trash can. LVN C said she worked the floor regularly but never heard the catheter bag was leaking. She stated she would provide another clean container for the patient to place the catheter bag so it would be away from the trash. LVN C stated the deficient practice could place the resident at risk for infection. On 08/25/2022 at 1:55 PM during an interview with the DON, she stated the deficient practice increased risk for infection for the resident. The DON said she was going to do in-service on the deficient practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521 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 2. Level of Harm - Minimal harm or potential for actual harm Resident #2 Residents Affected - Some Review of Resident's face sheet reflected resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2'ss diagnoses included essential hypertension, chronic pain, blood clot, and constipation. On 08/24/2022 at 11:07 AM, MA B was observed with three different blood pressure machines on the medication cart, each machine had a different cuff size (wrist cuff, upper arm medium cuff and upper arm large cuff). MA B was observed using the wrist-size cuff for Resident #2 after which he dropped the blood pressure machine on the medication cart among two other blood pressure machines. MA B failed to sanitize the equipment before and after using it on the resident. 3. Resident #1 Review of Resident #1's face sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension, gastro-esophageal reflux disease, generalized edema and constipation. On 08/24/2022 at 11:18 AM, MA B was observed using medium-size cuff machine to measure Resident #1's blood pressure, after which he dropped it on the medication cart among two other two blood pressure machines. MA B failed to sanitize the equipment before and after using it on Resident #1. 4. Resident #49 Review of Resident #49's face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension, anemia, constipation, and seizures. On 08/24/2022 at 11:28 AM, MA B was observed entering Resident #49's room to check his blood pressure using a large-size cuff machine. MA B removed the cuff from the resident and stated probably that was too big. MA B came out of resident's room and placed the cuff on the medication cart with the others. He then took the medium-size blood pressure cuff (same cuff he used for Resident #1 and used it for Resident #49, after which he placed it on the medication cart among two other blood pressure machines. MA B, failed to sanitize the equipment before and after using it on the resident. On 08/24/2022 at 11:47 AM during an interview with MA B, he stated he understood the deficient practice could place residents at risk for cross contamination because germs could have been transferred from one resident to another through the blood pressure machine he failed to sanitize. MA B stated he had been working with the facility for many years and had received trainings about prevention of infection. He also stated they had infection control training couple of times every month. On 08/25/2022 at 1:55 PM during an interview with the DON, she stated the residents were placed at risk for infection. She also stated they usually trained all their staff and they were also constantly having in-services on infection control and prevention. The DON said she was going to do an in-service related to infection control. On 08/24/2022 at 1:55 PM during interview with the Administrator, she stated they did not have policy that addressed sanitization of blood pressure cuff, she stated they were only following the best (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675079 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Allenbrook 4109 Allenbrook Dr Baytown, TX 77521 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 practice which was to sanitize equipment used for multiple residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 9 of 9