Health inspection·February 2, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 8.11%, based on 3 errors out of 37 opportunities, which involved 1 of 5 residents (Resident #19), and 1 of 4 staff (Medication Aide DD,) reviewed for medication errors. Residents Affected - Few -Medication Aide DD failed to administer 3 medications (Cyanocobalamin Tablet 1000 MCG. GlycoLax Powder (Polyethylene Glycol 3350 and Artificial Tear Solution) to Resident #19 according to physician orders. This failure could place residents at risk for not receiving therapeutic effects of their prescribed medications and possible adverse reactions. Finding include: Review of the admission Sheet for Resident #19 reflected she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #19 diagnosis included type 1 diabetes mellitus without complications (an autoimmune disease that leads to the destruction of insulin-producing pancreatic beta cells), cognitive communication deficit (difficulty with thinking and how someone uses language) and hypothyroidism (happens when the thyroid gland doesn't make enough thyroid hormone). Review of Resident #19's Comprehensive MDS, dated [DATE] reflected a BIMS score 12 out of 15 indicating intact cognition. Resident #19 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. Review of Resident #19's Care Plan initiated 08/27/2018 and revised on 09/11/2022 reflected the following: Focus; Alteration in bowel elimination relating to history of constipation. Goal: Resident will have soft formed stool every 3 days throughout the view date. Interventions: Administer Bisacodyl, Glycolax, Dulcolax, Linzess, Mineral Oil enema and sennoiside-docusate as ordered by MD and monitor effectiveness. Notify MD if not effective. Observation on 02/01/2023 beginning at 9:19 a.m. during med pass revealed , MA DD prepared, dispensed, and administered 8 medications to Resident #19. The medications observed were: -Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for Anemia. -Multivitamin Adult Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for vitamin supplement. -Potassium Chloride ER Tablet Extended Release 10 MEQ Give 1 tablet by mouth one time a day for Hypokalemia Take with food and 4-8 oz of water -Vitamin D3 Tablet (Cholecalciferol) Give 4000 unit by mouth one time a day for Supplement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675127 If continuation sheet Page 2 of 5 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 675127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Humble 93 Isaacks Rd Humble, TX 77338 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 0759 -Eliquis Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for DVT Level of Harm - Minimal harm or potential for actual harm -Metoprolol Tartrate Tablet 50 MG Give 50 mg by mouth every 12 hours for HTN Notify PCP if: HR greater than 100 or less than 60 SBP greater than 160 Hold for SBP less than 100 DBP less than 60 Residents Affected - Few -Sennosides-Docusate Sodium Tablet 8.6-50 MG Give 2 tablet by mouth two times a day for Constipation -Acetaminophen ER Tablet Extended Release 650 MG Give 1 tablet by mouth four times a day for pain. Once MA DD indicated to Surveyor she had completed Resident #19's medication administration for the scheduled 9am medications, further observation reflected MA DD failed to administer 3 prescribed medications. 1)Cyanocobalamin Tablet 1000 MCG Give 500 mcg by mouth one time a day for Anemia give two tabs to equal 1,000 mcg at 9:00am. 2)GlycoLax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for constipation (in Liquid) Mix with 4-8oz water and drink at 9:00 am. 3)Artificial Tear Solution Instill 1 drop in both eyes two times a day for Dry eyes at 9:00 am. Review of Resident #19's Physician Order dated 02/14/2020 reflected an order to administer Artificial Tear Solution Instill 1 drop in both eyes two times a day for Dry Eyes at 9:00 am. Review of Resident #19's Physician Order dated 06/13/2020 reflected an order to administer GlycoLax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for constipation (in Liquid) Mix with 4-8oz water and drink at 9:00 am. Review of Resident #19's Physician Order dated 04/10/2022 revealed an order to administer Cyanocobalamin Tablet 1000 Mcg Give 500 mcg by mouth one time a day for Anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues) give two tabs to equal 1,000 mcg at 9:00 am Review of Resident #19's MAR for 02/01/2023 revealed MA DD documented that Resident #19 was administered the following medications: Artificial Tear Solution Instill 1 drop in both eyes two times a day for Dry Eyes. GlycoLax Powder (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for constipation (in Liquid) Mix with 4-8oz water and drink. Cyanocobalamin Tablet 1000 MCG Give 500 mcg by mouth one time a day for Anemia give two tabs to equal 1,000 mcg. These medications were not observed being administered during med pass 02/01/2023 beginning at 9:19 a.m. Review of Resident #19's nurse's notes for February 2023, reflected no documented evidence found that the doctor was notified of the missed doses on February 01, 2023 for the medications prescribed. Interview on 02/01/2023 at 11:15a.m., MA DD stated the medications were scheduled to be administered at 9 AM and she could have a grace of 1 hour prior and 1 hour post 9 AM to administer medications safely. MA DD stated she went down the list and documented that she administered the medications without looking at the name of the medication today (02/01/2023) before moving to next resident for med pass. The surveyor reviewed med pass observation from earlier 02/01/2023 beginning at 9:19 a.m and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675127 If continuation sheet Page 3 of 5 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 675127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Humble 93 Isaacks Rd Humble, TX 77338 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed Resident #19's MAR with MA DD. MA DD stated, I did not give B12, glycolax and eye drops, I missed it, haven't given it. I am on my break I will give it to her on my next med pass time at 12pm. MA DD then raised her hands and walked away from the Surveyor. Interview on 02/01/2023 at 11:52a.m., the DON stated she started on December 2022 at this facility. She stated, I have provided a lot of training to staff its work in progress. She stated the expectation was for medications to be administered as ordered by the physician and standards of practice. The DON stated the risk to residents could have been a possible reduction in therapeutic efficacy of the medications. She stated it was brought to her attention that few medications were missed. She stated the ADON was calling Resident#19's physician to get a onetime order that way resident could get her missed meds. She stated she went and spoke to the resident and the resident was not sure what meds were given to her today, but the resident knew she did not get her eye drops. The DON stated she asked the resident if it was ok to be given missed meds late and resident agreed. The Surveyor shared MA DD's interview with the DON. Regarding MA DD stated she would give missed meds at 12pm and walked away. The DON stated MA DD had been working at this facility for the past 35 years. The DON stated she was new and was trying to get to know the staff. She stated the competency check were done annually. Review of facility's Administering Medications policy (Revised April 2019)) read in part: .Policy: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug . Review of facility's Administration procedures for All Medications policy (08-2020) read in part: .Policy: Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications. 111. 5 Rights (at a minimum): At a minimum, review the 5 rights at each of the following steps of medication administration. 1 Prior to removing the medication package/container from the cart/drawer: a. check the MAR/TAR for the order . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675127 If continuation sheet Page 4 of 5 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 675127 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Humble 93 Isaacks Rd Humble, TX 77338 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 0759 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675127 If continuation sheet Page 5 of 5