Health inspection·September 27, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 09/26/24 at 02:58 PM revealed ADM cleaning out and labeling items in the nourishment room refrigerator after interviews began of items not being labeled. During an interview with the DM on 9/27/24 at 2:51 PM she stated that all refrigerators were her responsibility to maintain. She stated it was her expectation that staff members keep their personal use items in the staff break room. She stated all items should have an expiration date of three days when they're opened. She does not expect dirty dishes to be stored or washed in the nourishment room. She stated that trays should be stored on top of the juice machine and not underneath the dishwasher next to chemicals. She expected that all drinks will be Saran wrapped or covered immediately after they're done pouring and that they should be labeled and dated and stored in the refrigerator. She stated that negative outcomes for improper storage or failing to maintain a clean environment/ equipment was contamination of the resident's food . During an interview with the ADM on 9/27/24 at 3:00 PM she stated that she expected the nourishment room to follow the posted rules. She took personal responsibility for the nourishment room and that the undated food and dirty dishes were unacceptable and out of policy. She says that she expected the DM to oversee all operations in the kitchen including proper food storage. She stated a potential negative outcome of not following the guidelines for proper storage, labeling and dating, and cleanliness was that it could make the residents sick . Review of undated facility policy posted on refrigerator states Items must have the resident's name and date on it. Food items are only good for three days then must be disposed of. House shakes must have a date on every container. Expiration date of 15 days once removed from the freezer. Review of facility policy titled Refrigerator and Freezer dated December 2014 stated all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from the cases for storage use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and used by dates indicated once food is open. Review of facility policy entitled Foods Brought by Family and Visitors dated October 2017 stated that non-perishable foods will be stored in a resealable container with a tight-fitting lid. Intact fresh fruit may be stored without a lid. Perishable foods must be stored in resealable containers with tightly fitting lids and all refrigerator containers will be labeled with residents name the item and use by date. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under [paragraph] (B) and in [paragraph] (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in [paragraph] 3-401.11(B) or reheated as specified in [paragraph] 3-403.11(E) may be held at a temperature of 54°C (130°F) or above; or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675140 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 675140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Hamilton 1315 East State Hwy 22 Hamilton, TX 76531 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 (2) At 5ºC (41ºF) or less. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. 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: 675140 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 675140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Hamilton 1315 East State Hwy 22 Hamilton, TX 76531 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one of one kitchen and one of one common areas (common area near the nurse's station) reviewed for pests. Residents Affected - Some 1. Houseflies, spiders, and crickets were seen in the common area by the nurse's station. 2. Insects and spiderwebs were present in the kitchen. This failure could place residents at risk of infection, discomfort, and diminished quality of life. Findings included: Observation on 09/26/24 at 02:28 PM revealed four houseflies flying in the common area near the nurse's station. Observation on 09/25/2024 at 9:10 AM revealed 1 cockroach walked across the floor in the dry storage area of the kitchen. Observation on 09/25/2024 at 10:45 AM revealed that there were multiple spider webs/ spiders and two crickets in the far-right corner of the dry storage area in the kitchen. Observation on 09/25/24 at 1:30 PM revealed one small dead cockroach in the clean dish area of the kitchen. Observation on 09/26/2024 at 2:28 PM revealed a large live spider in the hallway between the resident's room and the nurse's station. Observation on 09/27/2024 at 2:45 PM revealed spider webs and one dead cockroach in the main dining area. Observation on 09/27/2024 at 3:30 PM revealed spider webs and ants in the main conference room. During a confidential interview with eight residents on 9/26/2024 at 10:45 AM, they stated that they see flies around. They stated they believed pest control could be better. During a confidential interview with a confidential resident on 09/25/24 at 1:45 PM she stated that since her room was closest to the nurses' station, flies come in all the time. During an interview on 9/27/24 at 2:51 PM the DM stated that when she saw more than one bug, she wrote it down on the maintenance log to ask the maintenance people to take care of the pests. She stated she made sure that she communicated with the pest control guy when he came and that they swept and mopped all places daily. She said it was her expectation that her employees do not put food down the drain, take the trash out immediately, and make sure the trash cans were covered. She also said she did not leave wet mops out on the floor and ensured that the chemical room was cleaned, and wet rags were removed each day. The DM stated that if pests were around, they could contaminate the products and create an infestation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675140 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 675140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Hamilton 1315 East State Hwy 22 Hamilton, TX 76531 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 09/27/24 at 03:12 PM, the DON stated that from a clinical perspective having pests in the kitchen/food service areas, around clean dishes etc. was not sanitary. She stated the pests could get in the food or infect the food resulting in residents getting sick and she expected the kitchen staff to maintain sanitary conditions. During an interview on 09/27/24 at 03:31 PM, the ADM stated that they have the pest control guy on speed dial and he would be there within two hours, if they called him. She stated that they have been working on the bug problem, but it wasn't fixed yet. The ADM said it was her expectation that staff keep everything clean which included keeping the resident's bedside tables clean and ensuring that housekeeping was keeping the floors clean. The ADM stated a potential negative impact of pests in the facility were that it could make residents sick or uncomfortable and bugs would stress people out. Review record review of maintenance requests logs from 03/31/24 to 09/15/24 revealed that 12 out of 20 maintenance requests were due to pests in the facility. The pest complaints included scorpions, spiders, ants, roaches, and bed bugs. Review of record titled Notice of Pest Control Treatment provided by the ADM as the facility pest control contract stated that treatment services are provided on the 1st Thursday of every month by [pest control company]. Review of pest control invoices from April 2024 to September 2024 reflected the company treated the facility on 04/11/2024, 05/02/2024, 05/06/2024, 05/13/2024, 06/13/2024, 06/21/2024, 07/15/2024, 08/28/2024, 09/19/2024, 09/24/2024 with the most recent including bed bug treatment but did not reflect treatment for crickets, cockroaches, or flies. Review of facility policy dated 02/01/2017 and titled Pest Control reflected the following: our policy is that our facility maintains an effective pest control program. The facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675140 If continuation sheet Page 5 of 5