Health inspection·October 3, 2023

F 0700 was non-ambulatory and required a two person assist for bed mobility. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1 ' s care plan, revised 09/11/2023, revealed the resident had a history of falls and sliding off the bed with a recent fall on 9/16/2023 where he was found on the floor mat with no injuries. The care plan revealed Resident #1 had a focus of being unable to bear weight or walk and limitations to legs and shoulders with interventions to include bilateral transfer bars. The care plan did not address the residents risk of entrapment. Residents Affected - Few Bed Mobility Device Assessment Review of incident report log from September 2023 to October 2023 revealed Resident #1 had a fall on 09/16/2023 and incident category listed as other 09/30/2023. Review of Provider Timeline Report, dated 09/30/2023, revealed the following: *3:00 a.m., revealed CNA A last saw Resident #1 prior to incident during incontinent care check. *4:10 a.m., revealed CNA A found resident unresponsive with his head and neck between the assist bar and mattress. LVN A assessed, 911 was notified, AED device was placed by staff and CPR was initiated. EMS assisted with CPR. *4:38 a.m., EMS pronounced Resident #1 ' s death. *4:56 a.m., the administrator was notified of death. *5:17 a.m., revealed Regional Director of Operations was notified. *6:23 a.m., revealed police were notified. Three officers arrived, assessed incident, obtained witness statements, and notified the Justice of the Peace that ordered an autopsy. During an interview on 10/01/2023 at 11:35 a.m., the Administrator said the Director of Plant Operations was responsible for bed and assist bar installation and maintenance. The Administrator said CNA A last saw Resident #1 during incontinent care rounds at 3:00 a.m. on 09/30/2023 and he was doing fine and upon rounding at 4:10 a.m. CNA A noticed his legs were hanging off the bed and found him on the floor mat face down with his head and neck between the assist bar and bed. LVN A and the ADON assessed Resident #1 and there were no apparent injury or bruising at the time of the incident. AED device was obtained, and resident was a full code. CPR was initiated and EMS arrived and hooked him up to EKG, there were no readings, resident was determined deceased , and CPR was halted. The Administrator said Resident #1 ' s roommate was asleep and not aware of what had happened until the police came. The Administrator said Resident #1 ' s family member was notified by the ADON, and she called law enforcement and an autopsy was ordered. During an interview on 10/01/2023 at 3:39 p.m., CNA A said she went in to check on Resident #1 at 3:00 a.m. on 09/30/2023 and he was good, awake, and not trying to get off the bed. CNA A said when she went by his room at 4:10 a.m., Resident #1 was hanging off the bed with legs crossed on the floor, right arm was on the floor, and his neck was in between bed and rail. CNA A said she did not notice any injuries or bruising. CNA A said Resident #1 never used the assist bars on his bed and did not know why they were in place because he could not grip the bar to hold. CNA A said his bed did not appear to have any concerns with integrity of equipment. CNA A said it was important for assist bars (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675398 If continuation sheet Page 2 of 8 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 675398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Center 501 Timpson Center, TX 75935 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 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to be installed per manufacturer ' s specifications to prevent all residents from getting hurt and pose a risk of entrapment to all resident using assist bars. CNA A said the Director of Plant Operations was responsible for installing and maintaining assist bars on beds and the facility has not provided her any training on bed safety or assist bars. During an interview on 10/01/2023 at 2:49 p.m., LVN A said she last saw resident #1 during medication pass on 09/29/2023 at 9:00 p.m. and said he was at baseline. LVN A said maintenance, the Director of Plant Operations, would be responsible for installing assist bars on the beds. LVN A said when someone falls, she typically does interventions such as placing a fall mat or providing education. She stated she did not know why the assist bar were installed on the residents bed and she was aware they could pose a risk of entrapment. LVN A said it was important for assist bars to be properly installed to prevent injury or death for all residents. During an interview on 10/01/2023 at 12:28 p.m., the Administrator said following the incident with Resident #1, staff were in-serviced on bed safety and audit checks were completed on all resident beds with assist bars thoroughly checked and there were no concerns with integrity of assist bar equipment. During an interview on 10/01/2023 at 2:15 p.m., LVN B said she was informed Resident #1 had gotten out of bed and got hung in the rail. LVN B said Resident #1 was a repeat faller, could not walk, had little movement, and could get his legs off the bed somehow with fall risk interventions of fall mat at bedside and keeping his bed low to the floor. LVN B said he has rolled of the bed before and have caught him with his legs off the bed and had to reposition him. LVN B said she did not know why they put the assist bar on his bed . She stated she had no concerns related to the beds ,assist bars or the use of the rail bars. She stated if she did, she would report to maintenance, the Director of Plant Operations. LVN B said following Resident #1 ' s incident, in-services were provided on bed safety. LVN B said hazards with using air mattresses and assist bars on beds could pose a risk of entrapment. During an interview and observation on 10/01/2023 at 4:45 p.m., the Director of Plant Operations said the bed located in Resident #1 ' s room was the original bed and equipment for resident. The Director of Plant Operations said the bed manufacturer was [company 2], model P503, and the assist bar was manufactured by [company 1]. The Director of Plant operations said there was no gap allowed between the assist bar and bed for this type of assist bar. The Director of Plant Operations said he completed bed safety checks for all beds following Resident #1 ' s incident. The Director of Plant Operations said he was not aware that the assist bar was intended for use on[company 1].beds only per manufacturer ' s specification and that he installed the assist bars if the holes in resident bed frames lined up with the holes in assist bar. The Director of Plant Operations said it was important for assist rails to be installed properly to prevent the risk of injury or death and that improperly installed assist bars could pose a risk of entrapment. The Director of Plant Operations said he completed bed rail safety checks monthly and did not know if there were any [company 1]manufactured beds in the facility and that he did not keep an inventory of beds available. The Director of Plant Operations said the different white colored assist bars used in the facility were universal and that he did not have the manual for the universal assist bars. Review of [company 1] assist bar manual undated revealed the following: Warning: Possible Injury Or Death. This product is intended for use with [company 1] bed models ECS Series beds, B784, B694, B684, B624, B675, B530, B330, and B40/41. Use of this product on any bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675398 If continuation sheet Page 3 of 8 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 675398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Center 501 Timpson Center, TX 75935 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 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few it was not designed for could result in an unproven or unsafe configuration, potentially resulting in serious injury or death . and It is also extremely important to review the resident/patient ' s physical and mental condition and initiate an appropriate individual care plan to address entrapment risk. Resident #2 Review of face sheet for Resident #2, dated 10/02/2023, revealed she was a [AGE] year-old female admitted on [DATE] and had diagnoses including muscle wasting and atrophy to right and left shoulders, acquired absence of left leg above knee, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, age related osteoporosis, and encephalopathy. Review of Resident #2 ' s MDS, dated [DATE], revealed she a Brief Interview for Mental Status Score of 04, indicating severe impairment. Resident #2 ' s functional status revealed she was non-ambulatory and required a two person assist with bed mobility. Review of Resident #2 ' s care plan, revised 08/10/2023, revealed she required extensive assist of two staff with bed mobility with intervention of bilateral transfer bars to assist with positioning and care. The care plan did not address the residents risk of entrapment. Review of Bed Mobility Device Assessment for Resident #2, dated 09/30/2023, revealed no concerns for risks of entrapment and assist bars were installed for bed mobility. During an observation on 10/2/2023 at 1:25 p.m., Resident #2 had a white universal assist bar installed to [company 2] manufactured bed, model P503. During an interview on 10/02/2023 at 2:22 p.m., the Director of Plant Operations said he did not have a manual for the universal assist bars and provided a manufacture and model number of [company 3] 54588. Review of [company 3] 54588 assist bar manual from supplier online website, undated, revealed the following: Warning: Risk of serious injury or death. This product is intended only for use with [company 3] 1500, 3000, 3250, and 3500 beds. Do not use this device with any other model or brand of bed. Use of this product on any bed it was not designed for could result in an unproven or unsafe configuration, potentially resulting in serious injury or death. During an interview on 10/02/2023 at 3:30 p.m., the Executive Director of Operations, Regional Nurse, and Clinical Reimbursement Coordinator said they will address Resident #2 ' s [company 3] assist bar installed on [company 2] manufactured bed not intended for use as soon as possible following HHSC Investigator intervention to ensure safety. During an interview on 10/02/2023 at 3:50 p.m., the Executive Director of Plant Operations said [company 2] assist bar was available for Resident #2 ' s bed, however, the assist bar was removed following an assessment and determination that resident was not using assist bars as intended for repositioning and were removed with approval from the representative. During an interview and record review on 10/02/2023 at 3:53 p.m., the Clinical Reimbursement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675398 If continuation sheet Page 4 of 8 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 675398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Center 501 Timpson Center, TX 75935 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 0700 Coordinator revealed care plan verbiage to be added to residents with assist bars that included risk for entrapment. Level of Harm - Immediate jeopardy to resident health or safety Review of facility in-services, dated 09/30/2023, revealed bed safety education was provided to nursing staff. Residents Affected - Few Review of facility policy, titled Bed Safety, effective 04/2021, revealed the following: Policy Focused Communities will strive to provide a safe sleeping environment for the resident. PROCEDURE 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. An inspection should be done by the Director of Plant Operations at installation/before use and quarterly thereafter of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position. c. Ensure that when bed system components are worn and need to be replaced, they are replaced with compatible components that meet manufacturer specifications; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675398 If continuation sheet Page 5 of 8 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 675398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Center 501 Timpson Center, TX 75935 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 0700 d. Level of Harm - Immediate jeopardy to resident health or safety Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and . Residents Affected - Few 10. When using side rails for any reason, the staff shall take measures to reduce related risks. The Executive Director of Operations was notified of the Immediate Jeopardy on 10/02/2023 at 2:12 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on 10/03/23 at 12:54 p.m. and reflected the following: Part 1: Identification of Recipients: 1 The resident directly affected by the deficient practice is no longer in the community. Part 2: Actions to Prevent Occurrence or Recurrence: 1. Universal Assist bar was removed from additional resident with air mattress on 10/2/2023. 2. All facility policies and procedures regarding assist rails were reviewed during Ad Hoc QAPI with Medical Director on 10/2/23. 3. The DON or designee will educate all staff, prior to their next scheduled shift, on the proper use of assist rails per facility policy, the process of determining proper use of side rails depending on resident ' s mental and physical status, and the increased risk of injury and death when assist rails are used improperly. Education will include bed mobility device inspection, FDA recommended space and instruction to report gaps greater than recommendation to DON/Administrator/Maintenance Director. Education will begin 10/2/23 and completed 10/3/2023 before the start of their next scheduled shift. a. Newly hired personnel will be educated on the proper use of assist rails per facility policy, the process of determining proper use of side rails depending on resident ' s mental and physical status, and the increased risk of injury and death when assist rails are used improperly. 4. Maintenance personnel provided 1:1 inservice on installation of all assist bars per manufacture guideline on 10/2/2023 by the Regional Nurse. Manufacturer guidelines will be available to any staff installing assist bars. The guidelines will be located in the Administrator and Maintenance Director ' s office and at nurse ' s station. 5. The IDT reviewed all residents with assist bars to determine the appropriateness of continued assist bar placement and risk of entrapment on 10/2/2023. All residents utilizing assist bars will have a Bed Mobility Device assessment completed on 10-3-2023 by 1p.m. 6. The IDT reviewed the care plans of residents with bed rails to ensure they include risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675398 If continuation sheet Page 6 of 8 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 675398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Center 501 Timpson Center, TX 75935 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 0700 associated with use of assist bars completed on 10/2/2023. Level of Harm - Immediate jeopardy to resident health or safety On 10/03/23 at 5:30 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Residents Affected - Few Removal of assist bars not intended for use from beds and replacement with approved assist bar per manufacturer ' s specification, Review of in-services revealed staff training was completed on bed mobility zone gap recommendations, care plans updates included entrapment risk for residents with assist bars, interviews with staff demonstrating knowledge and location of bed mobility inspection sheet at nursing station, and bed inventory list with approved bed manufacture for assist bars used. During an interview and record review on 10/03/2023 at 4:03 p.m., the Executive Director of Operations said the interdisciplinary team consisted of the DON or Interim Administrator, MDS Coordinator, Activity Director, Social Worker, Rehab Director, ADON, Maintenance Director, Medical Director, and included herself. The Executive Director of Plant Operations said staff received in-services per plan of removal, care plans were updated to include risk of entrapment, and assist bars not intended for use were removed from service. The Executive Director of Operations said only[company 2] manufactured beds with[company 2] assist bars were now utilized for resident beds at the facility to ensure manufacturer specifications were being met and was in the process of obtaining and replacing approved beds. Review of resident assist bar audit tool, care plan tasks, and physician order listing report, dated 10/3/2023, revealed rental beds were listed, [company 2] manufactured beds were rented, care plans were updated, and physician orders revealed assist bars were in place for repositioning and turning of residents. The Executive Director of Operations said it was important for staff to follow the assist bar manufacturer guidelines to ensure they are properly installed and used accordingly to reduce risks for any hazards including injury or entrapment and that not following manufacturer ' s guidelines could pose a risk to the residents that are using assist rails. The Executive Director of Operation said the facility has reassessed residents with assist bars installed and determined that some assist bars were no longer needed based on their ability to use the bar as intended for bed mobility. The Executive Director said family was contacted to approve removal of bars prior to removal and education was provided to residents and representatives on risks of using them. The Executive Director of Operations said the facility provided a legend with 4-3/4 inch requirement on bed mobility inspection sheet from FDA (Food and Drug Administration) recommendation for Zone 3 between assist bar and mattress and that the sheet will be located at the nurse station in the bed assist form manual and provided to every employee. The Executive Director of Operations said completion of[company 2] manufactured assist bars installation on Drive manufactured beds will be done by the end of the day. Review of in-service, dated 10/02/2023, revealed training was provided to nursing staff on proper use of assist rails to include assessment for assist bars on care plan prior to usage. In-service revealed bed mobility inspection sheet that included gap recommendation of less than 4-3/4 for Zone 3 located between bed rail and mattress. During an interview on 10/03/2023 at 4:15 p.m., CNA B said she had been employed at the facility for 3 years and that training was provided on bed safety via in-services. CNA B said the maintenance man, Director of Plant Operations, would be responsible for installing bed rails or assist bars. CNA B said if assist bars were not installed per manufacturer guidelines it could pose a risk of entrapment and affect any resident with an assist bar. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675398 If continuation sheet Page 7 of 8 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 675398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Center 501 Timpson Center, TX 75935 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 0700 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 10/03/2023 at 4:23 p.m., CNA C said to ensure beds are safe she made sure the bed was low, and made sure bed rails are secure, and look for space in between assist bar and bed so residents cannot get stuck in between them and uses length of badge as a reference for gap recommendation. CNA C said it was important for assist bars to be installed properly to prevent entrapment and could pose a risk of death if installed on beds not intended for use. During an interview on 10/03/2023 at 4:41 p.m., LVN C said she had been employed by facility for a year and a half. LVN C said residents were reassessed for assist bar use and knew that one resident had assist bars removed due to risk. LVN C said the facility provided training on bed safety today and that maintenance would be responsible for installing assist bars on the beds. LVN C said it would be a risk if a bed was not intended for use with an assist bar because it may malfunction and cause a risk for entrapment. During an interview on 10/03/2023 at 4:48 p.m., LVN D said she had been employed for 3 and a half years. LVN D said the facility provided in-services and the manual at the nurse station goes over bed rails. LVN D said it was important to install the assist bar as intended to prevent incidents or accidents and said residents could fall and get injured and posed a risk for entrapment. LVN D said if there was gap in Zone 3 that was bigger than 4-3/4 she would notify maintenance and Administrator to make sure they addressed concerns. During an interview and record review on 10/03/2023 at 5:10 p.m., the Clinical Reimbursement Coordinator said blanks on the assist bar assessment audit tool were residents waiting on new beds. During an interview on 10/03/2023 at 5:20 p.m., the Director of Plant Operations said assist bars had been replaced and were now only using [company 2] brand assist bars., model P503 and P903. The Director of plant Operation said he reviewed with the Regional Nurse on how to properly install the Drive assist bars and ensure safety by making sure we are following manufacturer guidelines. The Director of Plant Operations said he was checking beds weekly for proper install and that all staff were provided and referring to gap recommendation of less than 4-3/4 on the bed mobility device inspection sheet for Zone 3 between bed rail and mattress. The Director of Plant Operations said staff are being asked questions and that a small test will be conducted on bed safety in a couple of days to demonstrate retention of knowledge. On 10/03/2023 at 5:30 p.m., the Executive Director of Operations was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675398 If continuation sheet Page 8 of 8