Inspection·July 30, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm discuss with resident the need to request pain medications before pain becomes severe, discuss with physician that for maximum pain relief pain medication are best given around the clock, with PRNs for breakthrough pain, and monitor for potential side effects of pain medication. Record review of Resident #1's physician's orders, dated 07/30/23, indicated he had this order: Residents Affected - Few *Hydrocodone-Acetaminophen Tablet 10-325mg - Give 1 tablet by mouth every 6 hours as needed for pain. The start date was 11/03/22. There was no end date. Record review of Resident #1's June 2023 MAR indicated Resident #1 was administered his hydrocodone-acetaminophen tablet medication at least one time a day on June 1st, and June 3rd through June 30th. Record Review of Resident #1's July 2023 MAR indicated Resident #1 was administered his hydrocodone-acetaminophen tablet medication at least one time a day on July 1st through the 13th, July 15th through the 24th, and July 26th through the 28th. During an interview on 07/29/23 at 10:55AM, Resident #1 said he was upset about his missing Norco (hydrocodone-acetaminophen) medication, and he was worried that the money for that came out of his pocket. He said he has not had any problems receiving his medication. During an interview on 07/29/23 at 1:59PM, the Administrator said she was unable to provide the narcotic sheet for the missing Norco (hydrocodone-acetaminophen) medication. She said both the medication card and the narcotic sheet had gone missing. She said the reason they noticed they were missing was because the resident's new card that had been ordered and came in and it was noticed that the partial card was missing. She said they figured that 4 pills went missing because when the medication was ordered the sheet showed that there were 6 pills left, and they checked Resident #1's MAR and 2 more pills had been marked as given. During an interview on 07/29/23 at 2:22 PM, LVA A said she worked 06/30/23 and 07/01/23 on the 2-10 shift. LVN A said she did not count with LVN C at the end of her shift on 6/30/23 around 10:00PM. She said she did count at the beginning of her shift with RN B on 06/30/23 around 2:00PM. She said she remembered the partial card of Resident #1's Norco (hydrocodone-acetaminophen) medication because she remembered giving it to Resident #1 during her shift. She said she thought LVN C took it because RN B told her RN B did not notice it was missing during her shift the morning of 07/01/23 During an interview 07/29/23 at 2:35PM, RN B said she worked the 6-2 shift on 06/30/23 and 07/01/23. She said she finished her shift on 07/01/23 at 2:00PM and counted with LVN A. She said they counted the narcotics and noticed the partial card of the hydrocodone-acetaminophen medication and the count sheet was missing. She said she did count narcotics on 07/01/23 at the 6AM shift change with LVN C, but she did not notice both the partial card of the medication and the count sheet was missing. She said she was trying to get started on her shift and did not think about it. She said she thinks it probably went missing on LVN C's shift. She was unable to provide a reason for why she felt that way. During an interview on 07/29/23 at 2:42PM, LVN C said he was working the 10P-6A shift on 6/30/23-07/01/23. He said he did not count with LVN A at the beginning of his shift at 10PM because LVN A was not feeling good and was in a rush to leave. He said he did count the narcotics at the end of his shift at 6AM with RN B and the count was correct. He said he worked PRN at the facility and has worked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675293 If continuation sheet Page 2 of 7 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 675293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Linden 1201 W Houston St Linden, TX 75563 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there for about 8 years. He said he had never had anything like that happen in the time he had worked as a nurse. He said LVN A was going around the facility telling everyone he was the one that took the medication. He said the facility has not found him guilty and the facility does not call him for work anymore. He said he has been a nurse for 23 years. He said the process for counting the narcotics was that the nurse that was leaving holds the book and the oncoming nurse counts the cards. He said it would be possible to miss a missing narcotic if someone took the card and the sheet. During an interview on 07/29/23 at 2:58PM, LVN D said the process for counting the narcotics at shift change was the off going nurse counts the book and the oncoming nurse counts the cards. They go through all the controlled medications. She said if someone took the card and the count sheet it would be possible to miss that a medication was missing. During an interview on 07/29/23 at 3:00PM, LVN E said the process for counting the narcotics was that the off going nurse counted the book and the oncoming nurse counts the medication cards. She said it would be possible to miss a medication if the card and the sheet were taken out of the cart. During an interview on 07/29/23 at 3:03PM, RN F said the process for counting narcotics was that the offgoing nurse counts from the book and the oncoming nurse counts the medication cards. She said they count all the cards at each shift change and they were supposed to keep the empty cards when the medication runs out for the DON to remove from the cart. She said she counted the amount of cards at each shift change to make sure no one has taken a card out of the cart. She said if someone took the card and the sheet out that it would be possible to miss that a medication was missing. During an interview on 07/29/23 at 9:28AM, the Administrator said she did not have a copy of the police report related to the drug diversion and was unable to provide one at that time. She said she should have obtained a copy before, but it was the weekend and the administrative staff at the police department were not in on the weekend. She said there were copies of the interviews that the police took when they were on site in the PIR. During an interview on 07/29/23 at 9:34AM, LVN G said she gave narcotics during her shifts. She said the process for checking narcotics at shift change was that the off going nurse checks the sheets in the book and the oncoming nurse checks the medication cards. She said that it was possible to miss a narcotic that was missing if someone had taken the card and the drug sheet. She said she signed out the medication from the count sheet as soon as she pulled it out of the cart. She said if there was missing pain medication a resident could suffer unnecessary pain and ineffective pain management. She said the nurse that has the keys was responsible for ensuring the narcotics were accounted for correctly and do not go missing. During an interview on 07/29/23 at 9:43AM, LVN E said a resident could suffer pain if their medication went missing, and they may not be able to get it. She said they would be at risk for ineffective pain management. She said the nurse that had the keys was responsible for ensuring the narcotics do not go missing and that they were counted. During an interview on 07/29/23 at 9:59AM, the Administrator said none of the 3 nurses that had access to the keys when the alleged drug diversion occurred had any prior incidents with missing medications in their personnel file. During an interview on 07/29/23 at 10:15AM, LVN A said the process for counting narcotics was the nurses would give and take report, then the off going nurse counts the sheets, and the oncoming nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675293 If continuation sheet Page 3 of 7 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 675293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Linden 1201 W Houston St Linden, TX 75563 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few counts the cards. She said she counted the amount of cards to ensure someone did not take a card and sheet. She said the nurses also keep the empty cards to give to the DON to waste the card. The nurses were responsible for ensuring that the narcotic counts were right and that none have gone missing. The resident could suffer uncontrolled pain and ineffective pain management if medications go missing. During an interview on 07/30/23 at 10:18AM, LVN C said the charge nurse and anyone that had possession of the keys was responsible for counting the narcotics and ensuring that the narcotics were not missing or diverted. He said the residents could suffer pain, and ineffective pain management. During an interview on 07/30/23 at 12:23PM, the DON said she did not think she had any competencies on the 3 nurses that were identified in the alleged drug diversion related to counting narcotics. She said they were definitely taught about how to sign out the narcotics and to count narcotics at shift change. During an interview on 07/30/23 at 12:25PM, the DON said she spoke with the corporate nurse and she said that there was not a competency or any proof that they taught the nurses to count controlled medications at the end of each shift or that they needed to be signed out. She said it was something that nurses learned in nursing school. She was unable to find it in any of the onboarding processes. During an interview on 07/30/23 at 1:11PM, the ADON said she got the call when LVN A came into work at 2PM on 07/01/23. LVN A told the ADON there was a missing card of hydrocodone-acetaminophen medication. LVN A told the DON she believed someone may have taken the card and the count sheet. The ADON said she notified the Administrator and DON and came up to the facility. She said she searched all over the facility and was unable to find either the card or the medication sheet . She said she checked the other medications for any discrepancies. On 07/01/23 Both RN B and LVN A were drug tested first and she notified LVN C to come in for a drug test. She said she called the police and they did an investigation on 07/01/23. The ADON said she contacted the physician about the possible diversion. She said the replacement medication card came in that day so the resident did not go without his pain medication. She said she questioned the nurses. RN B missed that the card was missing. LVN C could not remember if there was a card missing. LVN A and LVN C did not count on 06/30/23 because LVN A was not feeling good. She said the officer told them on 07/01/23 to get the urine tested in an outside lab. She said since then they had put in place a new count sheet to count every card that was in the narcotic box and they were not allowed to take the count sheets or the empty cards out of the cart. These in-services were taught on 07/03/23 and 07/05/23. She said the DON was to remove the empty cards from the carts daily Monday through Friday. She said they had not identified anyone that may have diverted the drug. She said all the staff that give medications were in-serviced on the new procedure. She said before the change of procedure, it was clearly possible that someone could take a medication card and the sheet and the nurses could not notice that a medication was gone. She said she was not aware of any previous incidents like that for the three identified nurses. She said the nurse who had the keys in their possession were responsible for keeping the narcotics locked and ensuring none were taken. She said both the off going and oncoming nurse were responsible for ensuring the narcotic count was correct at shift change. She said residents could suffer unnecessary pain and ineffective pain management if their pain medications go missing. She said if a pain medication went missing they would attempt to get other pain medication as ordered out of the E-kit. During an interview on 07/30/23 at 1:24PM, the DON said she was out of town on vacation and was called about 4 hydrocodone-acetaminophen tablets missing. She called the regional director to find out the process and how to move forward. The Administrator was notified. She asked the ADON and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675293 If continuation sheet Page 4 of 7 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 675293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Linden 1201 W Houston St Linden, TX 75563 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administrator if she needed to come into the building to assist, and they told her to stay on her vacation. She said she came back to work the following Monday on 07/03/23 and did in-services with the staff. She said they changed to the new count sheets after the drug diversion event and the nurses were supposed to turn in the empty medication cards and the count sheets to the DON when a medication runs out. She said those were then verified and turned into medical records to be filed. She said the nurses were supposed to count the amount of cards in the cart to ensure that a card and sheet were not taken out. These inservices were completed on 07/03/23 and 07/05/23. She said before the incident and changes to the procedure, someone clearly could have taken a card out and the sheet without the nurses noticing. She said the three nurses did not have any prior incidents like that in their personnel files. She said the nurse that has the keys was responsible for ensuring that the narcotic count was correct and that none have gone missing. She said the DON was also responsible for correct narcotic counts. She said at shift change both the off going and oncoming nurses were responsible for doing a narcotic count and making sure it was correct. She said if a pain medication went missing, the resident could go without the pain medication. She said they would have to pull the medication out of the electronic med cart. If the medication was not in the electronic med cart then they would have to call the pharmacy and get the medication there stat. She said the resident could suffer unnecessary pain and ineffective pain management until the medication arrived. During an interview on 07/30/23 at 1:37PM, the Administrator said on 7/1/23 about 2:00PM she was called by the ADON. She was notified about a missing partial card of Resident #1's medication. They were missing some Norco. The ADON said the oncoming nurse LVN A when counting with RN B found that there was a missing card of the Norco. There were 6 left when RN B ordered the new medication and they saw that 2 were given and they figured that 4 pills of Norco were gone. They identified 3 nurses had access to the keys, LVN A, LVN C, and RN B. They had them submit to a drug test on 07/01/23 and then sent it to a lab and they were all negative. They then notified the police on 07/01/23. They audited all the other narcotics and were unable to find any other discrepancies. They disciplined all three nurses because each nurse had a part in the failure. They implemented a new procedure to count the amount of cards and ensure that no one has taken the card and the sheet on 07/05/23. They also kept the empty cards for the DON to remove and ensure that none have gone missing. QAPI team met on 07/14/23 and they agreed with the changes and did not make any other changes. She said the nurses did not have any other incidents like that happen before. The nurses were responsible for counting the narcotics. The DON and the ADON were responsible for oversight and monitoring of the narcotics and that the nurses were doing the narcotic counts. If a drug was taken then they would check for pain medication in the electronic cart, and if they did not have any ordered medication in there they would check with the doctor to see if there was something else suitable for the resident. She also said there was a pharmacy down the road they could possibly get the medication from. Record review of a facility inservice, dated 07/05/23, was taught by the DON that the Nurses were to keep empty narcotic medication cards and the sign off sheet until the DON removes the empty card and sheet from the medication cart. Record review of a facility inservice, dated 07/03/23, was taught by the DON to nurses that there was a new count sheet to be used at shift changes that included a new procedure to count the amount of narcotic medication cards in the medication carts. Record review of a QAPI team sign-in sheet, dated 07/14/23, indicated the QAPI team met on 07/14/23, and met from 10:00AM to 10:30AM. Attendees included the ADON, DON, Administrator, and the medical director. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675293 If continuation sheet Page 5 of 7 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 675293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Linden 1201 W Houston St Linden, TX 75563 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Facility's policy, Discrepancies, Loss, and/or Diversion of Medications, effective September 2018, and revised August 2020, stated: Policy All discrepancies, suspected loss, and/or diversion of medications, irrespective of drug type or class, are immediately investigated and a report filed . .Procedures Immediately upon discovery or suspicion of a discrepancy, suspected loss or diversion, the Administrator, DON, and consultant pharmacist are notified and an investigation conducted. The DON leads the investigation . .II. Loss of Supply of a Medication 1. The DON investigates the suspected loss and researches all the records related to medication receipt, its use since receipt, and all persons involved with medication administration and the supply of medication and identifies the last known point in time that the medication was available. The pharmacy should be notified and the pharmacy should verify that the medication was dispenses. A thorough search is conducted in all drug storage areas, the resident's room, and any other locations where medications may have been used/placed during medication administration in an attempt to locate any missing container or medication supply. 2. If the supply cannot be found after a thorough investigation has been completed, a supply must be obtained for the resident. 3. Document the loss and the investigation process. Notify the prescriber and family if doses have been missed and/or follow facility policy. 4. If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited. If the audit reveals a particular individual or individuals who might be suspected of involvement with the loss, appropriate disciplinary actions are taken and deferred to human resource policies. 5. Appropriate agencies, required by state and federal law, will be notified . Record review of the Facility's policy, Storage of Controlled Substances, effective September 2018, and revised August 2020, stated: Policy Medications classified by the Drug Enforcement Agency (DEA) as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures . 5. Unless otherwise indicated in a facility policy and/or as required by state regulations, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675293 If continuation sheet Page 6 of 7 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 675293 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Linden 1201 W Houston St Linden, TX 75563 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 0602 following will be performed: Level of Harm - Minimal harm or potential for actual harm a. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel and is documented . Residents Affected - Few 7. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and documented on a Control Count Sheet (or similar form) or in accordance with facility policy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675293 If continuation sheet Page 7 of 7