Inspection·September 30, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Methodist hospital accompanied by 2 EMT staff, returned with orders that was verified by MD via Celo and ok to continue per MD, obtain vitals 128/72 68 97.9 20 N/C @2L, resident returned NPO with peg tube to left mid-abdomen and order for Diabetic source but will use Glucerna Carbsteady 1.2 @55ml/hr water flush @50ml/Q12hr until original feeding is available, all medication administered via peg tube, gall bladder drain at right abdomen replaced while at hospital stay no drainage at this time, 02 @2L n/c no acute distress noted, denies pain or discomfort noted respiration even and labored, resident has order for Meropene (antibiotic used to treat bacterial infections) lg q8hr X 6days r/t asp pna vial IJ triple lumen to right side of neck, accuchecks (blood glucose monitoring) monitoring d/t enteral feeding, notified RP of resident's arrival, continue to provide care Record review of Resident#1's physician's order dated 8/2/2024 revealed cleanse site around Cholecystectomy tube ( A catheter that drains excess bile and fluids from the gallbladder) every night and PRN every night shift and monitor output every shift; Cleanse stoma site with NS or wound cleanser pat dry, apply split dressing between skin & disk every night shift; Glycolax Powder - Give 17 gram via G-Tube one time a day for constipation; Famotidine Give 1 tablet via G-Tube one time a day for acid reducer; Intra right jugular Vein IV site clean every week and PRN if needed. One time a day every Sat for change weekly; Eternal Feed Order every shift auto water flush 100ML Q 6 hrs; Perform weekly skin assessment every day shift every 7-day(s) document C for Clear and A for Abnormal (D/C 8/3/2024); Monitor PICC Line for S/S of infection every shift (every shift for 6 days); Normal Saline Flush Solution. Use 10 ml intravenously every 8 hours for aspiration pneumonia PICC LINE-Flush with 10 Normal Saline every 8 hours if not used with the same frequency for medication administration; Cleanse site around Cholecystectomy tube every night and PRN as needed. Record review of progress note dated 8/12/2024 at 1:19pm revealed resident has completed IV abx and has central line to right IJ catheter is stitched in place per DON and stated resident may have to send to ER to remove, notified MD via CELO, awaiting MD response. Record review of Hospital ER notes dated 6/3/2024 at 8:41pm revealed CR#1 was transported to hospital, via ambulance, and admitted [DATE] at 1:14am. CR#1 had an admittance diagnosis of Pyelonephritis [N12]. The primary diagnosis was aspiration pneumonia of right lung, which included chronic airway obstruction, palliative care. On 6/14/2024 an open drain right; upper abdomen was placed in the abdomen (stomach) which the dressing last changed 4 days prior, 6/12/2024 a CVC triple Lumen Non-tunneled right internal jugular vein, which the last dressing changed 3 days prior. On 6/15/2024 at 12:06pm, CR#1 was discharged from hospital and the instructions were Cholecystostomy tube must remain in place for a minimum of 6 weeks or until cholecystectomy is performed; Tube should be exchanged every 8-12 weeks; tube should be flushed twice daily with 10cc normal saline; tube should remain to gravity bag drainage at all times; and consider placing patient on ursodiol. Record review of facility's Quality of Care policy dated 02/2017 and revised 01/2023 revealed, Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. *Colostomy, Urostomy, or ileostomy care. The community will ensure residents who require colostomy, urostomy, or ileostomy services, received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Record review of LVN A progress note on 6/3/2024 at 10:04 revealed, revealed resident was observed lying in bed with eyes closed not easily to arouse verbally but slowly awaken with sternal rub, resident lethargic did not eat breakfast or drink fluids with assistance this am, obtained vitals 122/93 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 2 of 6 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 09/30/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 92 97.7 20 93% @3L n/c, resident is not her usual self, notified MD via Celo (Communication line with medical doctors) sent recent labs via Celo for MD to review as well, [NAME] gave order for meropenem lg iv q 8hr x 7 days, called and spoke with RP-FM he gave verbal consent for PICC insertion, cont. to provide care. Record Review of the Skilled Charting forms dated between the dates of 8/2/2024 and 8/9/2024, revealed the nurses on all shifts completed assessments; however, failed to address the PICC line, which was not assessed for any condition. Review of text message and video texted from FM A revealed a photo time stamped 7/9/2024 at 8:25am showing the tube in a body area of a resident and a bandage with the date of 6/14; Second photo time stamped 8/12/2024 showing what appeared to be a bandage dated 7/30/2024 and a blue tab and the dressing dirty and coming up off the residents' body. During a telephone interview with FM A on 9/10/2024 at 9:48am it was revealed on 6/4/2024, he was notified by the facility that CR#1 was rushed to the Hospital ER. FM was informed by the Hospital ER that CR#1 had severe pneumonia, bilateral kidney infection, a gallbladder infection, and a UTI. After 3 weeks in the hospital, she was discharged with a gallbladder drain tube. FM A provided additional instances of concerns. o FM A stated on 7/9/2024, he visited CR#1 and noticed the dressing on her gallbladder drain tube had not been changed since 6/14/2024, which was the day prior to being released from the hospital during her 6/4/2024 visit. Furthermore, the dressing that was supposed to be around the gallbladder drain tube; however, was visibly off CR#1's body and the tube that was inserted in the stomach was coming out. FM spoke with CNA B who went to get the charge nurse. o FM A revealed CR#1 had another hospital ER visit on 7/29/2024, and while she was in the hospital, a Central Line (PICC line) was placed in her neck area for medications and along with the G-tube inserted for feeding and hydration, to help mitigate the risk of aspiration. CR#1 returned to the facility 7/30/2024. o FM A stated during another visit at the facility on 8/6/2024, at 8:30 AM. CR#1 began complaining of something biting her and itching. FM A called CNA A to come to the room to look at the mattress. CNA A rolled CR#1 on her side to see what was going on in the area his mom was lying. The bed was covered with live ants. FM stated CNA A went to get Maint. and another staff member for assistance. Both staff members assisted in getting CR#1 out of bed, cleaned up, and our of the room while the Maint. Sprayed the room with disinfectant which may have caused breathing issues. o FM A stated during another visit on 8/12/2024 it was observed that CR#1's Central Line (PICC) had not been changed since she returned to the facility on July 7/30/2024 from the hospital visit on 7/29/2024, which was 14 days prior. It was noted that the dressing was in an extremely unsanitary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 3 of 6 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 09/30/2024 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 0684 condition. Level of Harm - Minimal harm or potential for actual harm o Residents Affected - Few FM A stated on 8/21/2024 CR#1was again sent to the Hospital ER with breathing difficulties and diagnosed with sepsis (the body responds improper to the bacteria infection that affect the immune system) and a MRSA (a germ resistant to antibiotics and causes infection in different parts of the body. It is contagious) infection in her bloodstream. Her condition had significantly worsened due to, in FM A's opinion, the lack of proper care at the facility. On 9/10/2024 at 2:55pm during a telephone interview with RA witnessed ants CR#1's bed on 8/6/2024 . RA stated she reported this incident to Maint and LVN A. She stated she and another aide (Can't remember the name) got the resident out of bed and cleaned her up fast along with sanitizing the mattress and putting new bedding on. RA further confirmed the conversation with FM A regarding the unsanitary condition of CR#1's Central Line and that it had not been changed in 14 days. RA stated she did not look at the area; however, immediately went and got LVN A who accompanied her to CR#1's room. On 9/10/2024 at 3:11pm during an interview with LVN B it was revealed she had she been aware of report that the FM A had found ants in CR#1's bed by LVN A during shift change where staff exchange information regarding what issues, if any, occurred on their shift. LVN B stated CR#1 should have immediately been assessed to ensure there weren't any bites or other conditions; ensured the Maint was called and moved the bed from the window area if necessary and finally a notation would and should have been reported in PCC. Regarding the Central PICC, LVN B stated she was aware CR#1 had a Central PICC line on the right side of her neck and should have been flushed each shift. She further stated there is a kit in the medication room, which provide items to remove dressing, and re-apply adhesive around the outer side to prevent infection. LVN B stated this should be completed once weekly. She stated the dressing change on the PICC line was according to the order, to be changed on the weekends (Saturday). LVN B stated she did not clean or flush the PICC line because the order was for every Saturday and CR#1 never complained about the area. On 9/10/2024 at 4:30pm during an Interview with Maint revealed he was called to CR#1's room by the RA during the morning shift because there were ants in the bed. Maint witnessed about 3 ants (sugar ants according to Maint) and there were some cookie crumbs in the bed. At that time, CNA's helped the resident out of bed, stripped the bed, the resident was cleaned and placed in her wheelchair in the hall while he sprayed the room. The ants were also seen on the windowsill in the room. Maint stated there are no concerns of sugar ants and they come in the facility when it rains. He stated pest control comes monthly to spray but could not give an indication of all areas of applications other than internal applications. On 9/10/2024 at 5:00pm during an interview with LVN A stated she was aware of the gallbladder tube in CR#1's stomach and orders were to monitor drainage and tube base to make sure it's clean or dry. She confirmed she changed the dressing of the resident when FM brought it to her attention that the dressing was unsanitary and hadn't been changed. She stated CR#1's dressing should have been changed every 7 days. LVN A stated she completed on-going assessments of CR#1's gallbladder tubing area but did not notice the date nor change the dressing until it was brought to her attention . LVN A stated when dressing isn't changed it could cause infection and create a problem with the functioning of the tube. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 4 of 6 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 09/30/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN A stated she was working on 8/12/2024 and was aware the resident had a Central Line but does not remember FM A informing her about the condition of the dressing (unsanitary and dirty). She stated she flushed the line and ensured the medication was flowing like it was supposed to. With the line being in an unsanitary condition, it could cause the resident to have a risk of serious infection. LVN A stated when CR#1 returned from the hospital on or around the 7/30/24 she completed a head-to-toe assessment , noted orders from the hospital, took vital signs, reconciled medications with doctor for approval and completed documentation in PCC. The PICC line was not checked, and she stated she thought she had checked it. She stated when she failed to check the PICC line it did not populate in the orders and therefore nursing staff was unaware of the requirements for checking the PICC line area daily. LVN A stated she was never notified about ants in the resident's bed and was never notified of this fact. If she had been notified, she would have completed a head-to-toe assessment on CR#1for ant bites. On 9/11/2024 at 11:00am during an interview with DON who stated CR#1 returned to the facility on 8/2/2024 with a Central Line (PICC). She was not considered a Skilled Charting (An assessment of a high-risk resident on each shift for a period of time) resident , which would require a head-to-toe assessment each shift, which would have noted the nursing staff addressed the PICC line. The DON stated CR#1 was not considered a Skilled Charting resident and was unable to explain the reason other than residents on a Skill Charting level is determined by the business office. He further stated residents stay on Skill Charting only a certain number of times. The DON was unable to give an exact date resident was on Skill Charting or removed. The DON stated the nursing staff requirement for tube care for a resident who has a Central Line (PICC), colostomy bag, cholecystectomy tube or any type IV insertion, the area must be checked for any drainage amount and check for s/s of infection and continue to monitor that the tube stays intact. The DON stated failure to ensure the tube was intact could result in the tube leaking inside resident, which could very well cause sepsis. It was further stated the dressing around the area should not be dirty and the nurses are expected to keep that area clean. However, if the gallbladder dressing isn't dirty or draining there is no reason to bother it regardless of how long it's been there. She also stated it was not a problem if the dressing appeared to come off the tube; it just showed it needed to be changed. The DON stated the PICC line dressing should be changed every 7 days and it is unacceptable if it wasn' t. The DON stated the risk is the resident would get an infection. The DON reiterated that each Saturday the dressing should have been changed during day shift (6am - 2pm); however, the order went in on August 2nd at 8:20pm and since the resident came in with a PICC line from the hospital the dressing is clean and the nurses would not have change it. On 9/10/2024 at 3:11pm during an interview with LVN B Nurse stated she was informed during shift change by LVN A that FM found ants in CR#1's bed. LVN B stated CR#1 should have immediately received a head-to-toe assessment . LVN B stated she was aware of CR#1's Central PICC line on the right side of her neck and should be flushed each shift. However, the only order for the PICC line was to be cleaned and dressing changed on weekends (Saturday). LVN B stated when the resident returned to facility from the hospital, if the PICC line had been checked, it would have populated the cleaning along with the weekly dressing change for all shifts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 5 of 6 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 09/30/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 9/11/2024 at 3:55pm during an Interview with Admin revealed he assumed the nursing staff were changing the dressing on the gallbladder and the dressing on the Central PICC line for CR#1. He stated the nursing staff should have completed and on-going monitoring of the two areas to ensure there were no signs or symptoms of infection. He stated he will ensure staff received in-service training and education on skin assessments, environmental. In reference to the ants, he stated an assessment of CR#1 should have been completed. He stated there is an ongoing pest control application. There was an application on 8/5/2024. He stated to his knowledge there isn't an ant problem. On 9/27/24 at 7:24am during a telephone interview with MD - revealed CR#1 had a central line (PICC) at some point in the past, but what CR#1 had at the facility was a CVC (used for short-term access. A needle puncture to the vein in the neck, groin or upper chest) used to administer drugs, and fluids. MD stated CR#1 is still his patient even at her current facility. MD stated in June CR#1 went to the hospital for gallbladder issue, but the risk of surgery was to high based on her physical condition. MD stated that CR#1 has had several PICC lines in the past. However, the PICC lines can't stay in too long because of her historical health. MD stated this facility is a good community that continues to communicate with him regarding all his patients, especially CR#1. MD stated the facility calls often regarding concerns with CR#1's condition. MD stated he has had no problem with the care the facility gave CR#1. MD stated the correlation between Mrsa and the bandage is with mrsa there would have been a large abscess in the area if the bandages had infected the resident. MD stated CR#1 had colonization on her skin and changing the bandage too often would have created a secondary cross-contamination, which is what medical personnel wanted to avoid. MD stated that the bandage being dirty was not an issue at this time for CR#1, unless it was saturated with blood that was visible, had a foul odor and/or was really wet, which was not the case with her. MD stated the facility monitored CR#1 very closely and he was aware of her conditions and/or changes immediately. MD stated CR#1 has an enormous amount of risk factors for infection. MD stated CR#1 was recently released from the hospital to her current nursing facility and has had to be returned to the hospital for other medical issues. MD stated CR#1 will always have infections and other health issues and go back and forth to the hospital due to her medical condition. MD reiterated he had no concerns with her treatment at the facility and was always aware of CR#1 health issues when they occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675079 If continuation sheet Page 6 of 6