Health inspection·November 15, 2023

F 0641 section was signed by the MDS Nurse on 12/22/22. Level of Harm - Minimal harm or potential for actual harm Record review of the EMR Weights/Vitals section indicated Resident #4 had no weight documented for December 2022. Residents Affected - Few Record review of an annual MDS dated [DATE] indicated Resident #4 weighed 230 pounds and was marked for loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS section was signed by the MDS Nurse on 02/09/23. Record review of the EMR Weights/Vitals section indicated on 02/02/23 Resident #4 weighed 230 pounds. Record review of a quarterly MDS dated [DATE] indicated Resident #4 weighed 230 pounds and was marked for loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS was signed by the MDS Nurse on 05/25/23. Record review of the EMR Weights/Vitals section indicated on 05/08/23 Resident #4 weighed 223.5 pounds. Record review of a quarterly MDS dated [DATE] Resident #4 weighed 230 pounds and was marked for loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS was signed by the MDS Nurse on 08/14/23. Record review of the EMR Weights/Vitals section indicated on 08/04/23 Resident #4 weighed 221 pounds. During an interview on 11/14/23 at 02:47 p.m., the MDS Nurse said she would look at the resident chart to obtain the weight for the month to place on the MDS. She said the weights would carry over from the previous MDS. She said she did not check the weights and change them for the MDSs on Resident #4. She said the incorrect documented weight would make the MDS inaccurate. During an interview on 11/15/23 at 12:37 p.m., the Corporate Regional Director of Operations said MDSs carried over the previous weights so the MDS Nurse was supposed to change the weight according to the resident's current weight in the chart. She said the MDS nurse evidently did not change the weights for Resident #4 on the MDSs. During an interview on 11/15/23 at 12:45 p.m., the DON said they did not have an MDS policy. She said they followed the guidance of the current RAI Manual for accuracy of the MDS. Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled,K0200: Height and Weight indicated B. Weight (in pounds). Base weight or most recent measure in last 30 days; measure weight consistently; according to standard facility practice (e.g., in a.m., after voiding, before meal, with shoes off, etc.) Steps for Assessment for K0200B, Weight: 1. Base weight or most recent measure in last 30 days. 2. Measure weight consistently in accordance to facility policy and procedure, which should reflect current standards of practice (shoes off, etc). 3. For subsequent assessments, check the medical record and enter the weight taken within 30 days if the ARD of this assessment. 4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 2 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were screened for 1 of 6 residents reviewed for PASRR (Resident #42) Residents Affected - Few The facility did not have an accurate PASRR level 1 screening for Resident #42 upon admission, therefore a PASRR Evaluation was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 11/14/23 indicated Resident #42 was a [AGE] year-old male admitted [DATE] and readmitted [DATE]. He had diagnoses of depression (mental illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent and excessive worry that interferes with daily activities), and bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs). There were no diagnoses of dementia or Alzheimer's disease. Record review of a quarterly MDS dated [DATE] indicated Resident #42 was cognitively intact with a BIMS score of 15 out of 15; he had no diagnoses of dementia or Alzheimer's disease; he had diagnoses of anxiety disorder, depression, and bipolar disorder; and he received and antidepressant medication. Record review of a PASRR Level 1 Screening completed by the transferring facility dated 02/27/23 indicated Resident #42 was negative for mental illness. The sections for Exempted Hospital Discharge or Expedited admission were both marked no. Record review of Resident #42's EMR from 02/28/23 through 11/15/23 concluded there was no PASRR Level II (PE) Evaluation or Form 1012 (Mental Illness/Dementia Resident Review) included. During an interview on 11/13/23 at 03:20 p.m., the MDS Nurse said all resident referrals went through a corporate clinical team to determine if the resident met criteria for a P1 to be positive for MI, ID, or DD. She said she would usually check behind them to ensure the information was correct. She said Resident #42 was missed by the clinical team and herself. During an interview on 11/14/23 at 03:17 p.m. the MDS Nurse said Resident #42 was missed as having a mental illness with no diagnoses of Alzheimer's disease or dementia and she was instructed to fill out form 1012 to correct the negative PASRR 1. She said Resident #42 would be seen by the LMHA to be evaluated for MI to determine if he met the criteria for PASRR positive She said the potential risk of a resident not being identified as having MI, ID, or DD was a resident might not receive services they deserved or needed. During an interview on 11/15/23 at 2:30 p.m., the DON said they did not have a PASRR policy. She said they followed what PASRR and the RAI Manual regarding PASRR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 3 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. Event ID: Facility ID: 675602 If continuation sheet Page 4 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 10 residents reviewed for comprehensive care plans. (Residents #6 and #42) The facility did not develop a care plan for Resident #6 addressing his smoking, behaviors, resistance to care, or his full code status upon readmission. The facility did not develop a care plan for Resident #42 addressing his bipolar disorder diagnosis, Factor 5 Leiden mutation diagnosis, or anticoagulant medication upon admission. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated 10/23/23 indicated Resident #6 was an [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), respiratory failure (a serious condition that makes it difficult to breathe on your own), hypertension (a condition in which the force of the blood against the artery walls is too high), congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak and becomes stiff and unable to fill properly), history of tobacco abuse and dependence (smoker), and chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe). Record review of the admission MDS dated [DATE] indicated Resident #6 was marked yes for current tobacco use. Record review of physician orders for November 2023 indicated Resident #6 had an order dated 11/09/23 for Full Code status and to monitor for behaviors due to diagnosis of paranoid schizophrenia (a mental illness that can cause severe disruptions in a person's life because it affects their connection to reality due to delusions and hallucinations). Record review of Progress Notes with nursing documentation for Resident #6 indicated: * on 10/22/23 at 11:45 a.m. he said another resident came by his motorized wheelchair and tried to hit him. He yelled and cussed at the other resident, grabbed the other resident's Foley catheter tubing, and threatened to kill the other resident. * on 10/23/23 at 10:30 a.m. he was smiling and talking to himself. * on 10/23/23 at 04:10 p.m. physician was notified of the resident talking to himself and diagnosis of paranoid schizophrenia. Physician said he would evaluate the resident at that time. * on 10/24/23 at 03:54 p.m. an order was received to administer Trazadone (antidepressant) at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 5 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0656 bedtime for sleeplessness and an order to restart Geodon (antipsychotic) for paranoid schizophrenia. Level of Harm - Minimal harm or potential for actual harm * on 10/25/23 at 07:20 a.m. he went into another resident room and cussed the resident. He yelled and said he would kill the other resident. Staff intervened and removed him from the other resident room. NP was notified. Residents Affected - Some *on 10/25/23 at 08:15 a.m. an order was received to send him to the ER for evaluation. *on 10/25/23 at 09:40 a.m. ER physician notified of resident diagnosis of paranoid schizophrenia and medications started. Also ER physician was made aware of the resident's increased in physical and verbally aggressive behaviors towards other resident in facility and threats to kill other resident. *on 10/27/23 at 12:57 p.m. facility spoke with representative of behavioral health center where resident was admitted . * on 11/10/23 at 01:38 p.m. he refused the Nicotine patch. He said he smoked and did not need the patch. * on 11/12/23 at 09:04 p.m. he threatened multiple residents. He was seen yelling at the walls. He would go into his room yelling with no one in his room. He said people were going into his room but no one had been in the room. He refused his medications. An order was received to send him to the ER for readmission to the psychiatric hospital. EMS arrived to transport him and he slammed the door saying he was not leaving. The police were contacted and came. They spoke with him which he calmed down. He was heard yelling in his room but was not threatening anyone. * on 11/13/23 at 03:14 p.m. he was heard arguing in his room with someone who was not present about money and paying them 100,000 dollars and killing someone. * on 11/13/23 at 05:07 a.m. the nurse smelled smoke in the hallway. He had a pack of cigarettes lying on his bedside table. He said he was not smoking but nurse could smell smoke in his room. The nurse removed the cigarettes and lighter from his room telling him they would be in the cigarette box. He tried to get the cigarette box but the nurse blocked the drawer where it was located. He was told it was illegal to smoke in the building because it was a nursing home which he cussed at the nurse. * on 11/14/23 at 12:00 a.m. resident became angry and did not want to go to his scheduled appointment. Resident attempted to use a wheelchair to barricade his door. The wheelchair was removed for safety. * on 11/15/23 at 01:03 a.m. he had wheelchair, bed side table, and chair attempting to barricade his door. They were removed from the door for safety. Record review of Resident #6's care plans dated 11/09/23 indicated there were no care plans addressing his full code status, his smoking, his behaviors, or his resistance to care. During an interview on 11/13/23 at 01:30 p.m. MA A said Resident #6 was known to have behaviors. She said he was physically and verbally aggressive towards other residents and staff. She said he had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 6 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0656 been started on new medications because of his behaviors. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/15/23 at 12:00 p.m. CNA D said Resident #6 was known to have behaviors of cussing at other residents and staff at times She said he was sent out to the psychiatric hospital for the behaviors. Residents Affected - Some During an interview on 11/15/23 at 11:45 a.m., the DON said she and the MDS Nurse were responsible for the care plans. She said she cancelled all of Resident #6's previous care plans because he was discharged to the psychiatric hospital. She said she did not realize he had to be discharged for 30 days or more before she was to start a new care plan. She said a new care plan was started on Resident #6 but it did not address his smoking, full code status, or behaviors. She said he still smoked, he was a full code, he was still having behaviors, and he still resisted care. 2. Record review of a face sheet dated 11/14/23 indicated Resident #42 was a [AGE] year-old male admitted [DATE] and readmitted [DATE]. He had diagnoses of bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and a hereditary deficiency of other clotting factor. Record review of a hospital History and Physical dated 02/18/23 indicated Resident #42 had a diagnosis of Factor 5 Leiden mutation (hereditary deficiency of blood clotting factor). Record review of the admission MDS dated [DATE] indicated Resident #42 had a diagnosis of bipolar disorder and a diagnosis of hereditary deficiency of other clotting factor (Factor 5 Leiden mutation). Record review of the quarterly MDS dated [DATE] indicated Resident #42 had a diagnosis of bipolar disorder, a diagnosis of hereditary deficiency of other clotting factor, and received anticoagulant medication. Record review of physician orders for November 2023 indicated Resident #42 had an order dated: * 03/01/23 to monitor for signs and symptoms of adverse reaction every shift for warfarin (anti-coagulant) * 10/23/23 for warfarin 3 mg daily every Monday, Wednesday, and Friday. * 10/23/23 for warfarin 4 mg daily every Tuesday, Thursday, Saturday, and Sunday. Record review of Resident #42's care plans dated 09/28/23 indicated there was no care plan addressing the bipolar diagnosis, Factor 5 Leiden mutation diagnosis, or the warfarin. During an interview on 11/15/23 at 11:45 a.m. the DON said she and the MDS nurse were responsible for the care plans. She said they missed developing a care plan to address Resident #42's bipolar disorder, blood clotting disorder, and his anticoagulant medication use. Record review of a Comprehensive Care Plan policy revised 04/25/21 indicated: Policy: Every resident will have an individualized interdisciplinary plan of care in place. A baseline care plan to meet the resident's immediate needs shall be developed within forty-eight (48) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 7 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0656 Level of Harm - Minimal harm or potential for actual harm hours of Admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (DS 3.0) and CAAs, completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual, or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 8 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 2 residents (Residents #38) reviewed for enteral feeding. The facility failed to change Resident #38's enteral feeding set/bag every 24 hours on 11/12/23 and did not follow physician order to provide enteral feeding only 20 hours daily on 11/13/23. These failures could place residents receiving enteral nutrition at increased risk of not receiving the proper nutrition and infection. Findings included: Record review of Resident #38's face sheet dated November 2023 indicated he was [AGE] years old and admitted to the facility 02/17/22. His diagnosis included dysphagia (difficulty or discomfort in swallowing) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review of physician orders indicated he was to receive enteral feeding (a way of delivering nutrition directly to your stomach) of Nutren (a ready-to-use liquid tube feeding formula) 1.5 at 60 Ml/Hr with 30 Ml/Hr water flush every hour for 20 hours daily. Record review of care plans dated 10/09/23 indicated Resident #38 required enteral feeding related to aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) and swallowing problem. Record review of Resident #38's significant change MDS dated [DATE] indicated he had severely impaired cognition, had active diagnosis of dysphagia and gastrostomy, and received nutrition through a feeding tube. Record review of Resident #38's MAR dated November 2023 indicated he was to receive enteral feeding of Nutren 1.5 60 Ml/Hr continuous with 30 Ml/Hr water hourly for 20 hours daily and feeding was to be started daily at 11:00 a.m. During an observation on 11/13/23 at 08:37 a.m., Resident #38 was lying in bed with the head of bed up 45 degrees. His enteral feeding was running via a pump at Nutren 1.5 60 Ml/Hr and water 30 Ml/Hr. The bags were dated 11/11/23 at 11:00 a.m. During an interview on 11/13/23 at 09:26 a.m., the ADON said she was the LVN caring for Resident #38. She said his feeding bag and tubing and the water bag and tubing should be changed every 24 hours, but it had not been changed since 11/11/23 at 11:00 a.m. She said the feeding was to run 20 hours daily and should be turned off daily at 7:00 a.m. and restarted at 11:00 a.m. but she had not turned it off this morning as ordered. She said possible negative outcome of not hanging a new feeding and water bag every 24 hours could be infection or dried/hardened feedings that could cause the G-tube to become blocked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 9 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation and interview on 11/13/23 at 09:48 a.m., the DON viewed Resident #38's enteral feeding and agreed the bags and tubing were last changed 11/11/23 at 11:00 a.m. as labeled. During an interview on 11/13/23 at 03:45 p.m., the enteral feeding bags and tubing should be changed every 24 hours to prevent the chance of infection for the resident. She said Resident #38's feeding was not turned off at 7:00 a.m. as ordered. During an interview on 11/15/23 at 10:15 a.m., the Administrator said she expected nurses to follow physician orders and standards of practice for enteral feeding administration. She said the DON was the direct supervisor of all nursing staff and she expected the DON to monitor to ensure enteral feedings were administered correctly. Record review of facility policy titled Enteral Nutrition effective April 2020 indicated in part .Enteral nutrition will be ordered by the physician . The policy did not address how often tubing and enteral feeding bags should be changed. Record review of National Library of Medicine article titled Safety of Enteral Nutrition Practices: Overcoming the Contamination Challenges indicated in part .Ready-to-hang liquid formulas can be used up to 24 hours once opened FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 10 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 32 opportunities, resulting in a 6.25% percent medication error involving 1 of 6 residents (Residents #37) reviewed for medication pass. MA A failed to administer 2 scheduled doses of the medication Lyrica 50 mg (used to treat chronic pain) as ordered by the physician for Resident #37 on 11/13/23 beginning at 9:08 a.m. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. Findings included: Record review of the face sheet dated indicated Resident #37 was an [AGE] year-old female admitted on [DATE] with diagnoses included muscle spasms. She was readmitted [DATE] with diagnoses of fractures of 3 thoracic vertebra (backbone to which ribs are attached and her left tibia (the larger of the 2 bones in the lower leg) after a fall. Record review of an admission MDS assessment dated [DATE] indicated Resident #37 had moderately impaired cognition with a BIMS (brief interview for mental status) score of 10 out of 15. Her pain interference with day-to-day activities was rarely or not at all and her worst pain was moderate pain level over the last 5 days. Record review of a care plan reviewed on 11/13/23 indicated Resident #37 was at risk for pain related to fractures and back spasms. Record review of the physician order summary dated November 2023 indicated Resident #37 was to receive Lyrica 50 mg 1 PO three times daily. During an observation and interview on 11/13/23 beginning at 9:08 a.m., MA A prepared Resident #37's medications and said Resident #37 was out of Lyrica 50 mg. MA A walked to the medication room and looked for the resident's medication in the medication room. She said she ordered the medication last Thursday (11/09/23) and said the medication was not received . During an observation and interview on 11/13/23 beginning at 1:40 p.m., MA A said Resident #37's Lyrica medication was not received, the pharmacy sent the wrong medication. She said she was unable to give the 2nd dose of the scheduled dose of Lyrica 50 mg for the 2:00 p.m. dose. During a record review of the MAR November 2023 for Resident #37 indicated she was to receive Lyrica 50 mg 1 PO three times daily; there was no indication the medications were administered by MA A on 11/13/23 at 9:00 a.m. and 2:00 p.m. During an interview on 11/13/23 at 3:00 p.m., the DON said the pharmacy sent the wrong medication today after the nurse called the pharmacy to reorder the Lyrica. The DON said she notified the physician of the 2 missed doses of Lyrica 50 mg for Resident #37. The DON said her expectations were for the staff to follow the policy for medications to be refilled timely and for the staff to have 3 days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 11 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0755 of medications on hand at all times. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/14/23 at 4:45 p.m., the Administrator said her expectation was for her staff to follow policy and procedures to prevent medication issues such as not having medications available. Residents Affected - Few Record review of the facility's policy titled Ordering and Receiving Medication dated 08/2020 indicated Medications and related products are received on a timely basis.Reorder medications based on the estimated refill date on the pharmacy label or at least three days on hand in advance to ensure an adequate supply is on hand.- this is kind of a pharmacy tag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 12 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 1 of 13 residents (Resident #13) reviewed for unnecessary medication. Residents Affected - Few The facility failed to monitor Resident #13 for side effects from 11/01/23 to 11/15/23 of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk for adverse consequences such as bleeding, bruising, and black colored stools related to the use of the anticoagulant medication. Findings included: Record review of Resident #13's face sheet, dated 11/13/23, indicated an [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis which included atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots in the heart and increases the risk of a stroke). Record review of physician orders dated November 2023, indicated Resident #13 was prescribed Eliquis 5 mg two times a day for atrial fibrillation with a start date of 09/13/23. The orders did not address monitoring the anticoagulant medication. Record review of a care plan, initiated 09/13/23, indicated Resident #13 received an anticoagulant medication, called Eliquis with interventions which included monitor for side effects. Record review of an admission MDS, dated [DATE], indicated Resident #13 had a BIMS score of 00, which indicated severely impaired cognition. Resident #13 had a diagnosis of atrial fibrillation and received an anticoagulant medication 6 of 7 days during the look back period. Record review of a MAR, dated 11/14/23, indicated Resident #13 received Eliquis 5 mg two times a day from 11/01/23 to 11/04/23, 11/6/23 to 11/7/23 and 11/09/23 to 11/14/23 with a start date of 09/13/23. On 11/05/23 Eliquis 5 mg was received one time a day due to refusal and on 11/08/23 one time a day due to hospitalized . Record review of the electronic record for Resident #13 from 11/1/12 to 11/15/23 indicated the nurses did not document monitoring of side effects of the anticoagulant medication daily with medication administration. During an interview on 11/14/23 at 3:01 p.m., LVN B said she was assigned to provide care for Resident #13. She said all residents on anticoagulant medication should be monitored for side effects including bleeding and bruising. LVN B said the MA gave anticoagulants such as Eliquis and the nurse monitored for side effects. LVN B said she was the nurse who admitted Resident #13 and she must have forgotten to put the monitoring for the anticoagulant into the computer system. She said the admission nurse was responsible for putting the monitoring into the system, the ADON and DON were responsible for double checking the monitoring was put into the system for anticoagulants. She said she did not remember getting in-serviced on monitoring for anticoagulants but knew to monitoring for bleeding. LVN B said the risk of a resident on anticoagulants not being monitored for side effects was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 13 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0757 bleeding, bruising, and/or dialysis residents could possibly bleed out. Level of Harm - Minimal harm or potential for actual harm During an interview on 11/14/23 at 3:22 p.m., MA C said she was providing care for Resident #13 today. She said there was no monitoring on Resident #13's anticoagulant medication and there should be. MA C said she was responsible for giving Eliquis to Resident #13 and the nurse was responsible for monitoring Resident #13 for the side effects of the anticoagulant medication. She said she was not in-serviced on monitoring of anticoagulant medication for side effects but if a monitoring popped up in the computer, she would monitor for it. She said she knew to monitor for bleeding and bruising on residents on anticoagulant medication. She said the nurses were responsible for monitoring side effects and entering it into the computer system. MA C said the risk of a resident on anticoagulants who were not monitored was bleeding, bruising and blood clots. Residents Affected - Few During an interview on 11/14/23 at 3:45 p.m., the DON said the nurse admitting a resident was responsible for inputting the monitoring of anticoagulants into the computer system. She said the MA gave anticoagulants such as Eliquis to the residents and the nurse monitored the resident for side effects of the anticoagulants. The DON said she and the ADON were responsible for a double check for monitoring of anticoagulant medication. She said the staff had not been in-serviced on monitoring for side effects. She said Resident #13 was not monitored for side effects of his anticoagulant medication and should have been. The DON said when she started working at the facility on 08/23/23, she did not know to put the monitoring template into the computer system. She said she was in the process of auditing charts and had not started on anticoagulants yet. The DON said her expectation was when the admission nurse entered the order for an anticoagulant into the system to enter the monitoring template into the system so the medication would be monitored. She said the risk of a resident on anticoagulant medication not monitored was the risk of bleeding and bruising. During an interview on 11/14/23 at 4:01 p.m., the Administrator said the nurses were responsible for inputting the monitoring for anticoagulant medication into the computer system. She said Resident #13's anticoagulant medication should have been monitored for side effects and was not. The Administrator said the risk of a resident not monitored for side effects of anticoagulant medication was bleeding, bruising and medical issues. During an interview on 11/14/23 at 4:30 p.m., the DON said the facility did not have a specific policy for monitoring anticoagulant medication. Record review of a policy revised 08/2020, titled, Administration Procedures for All Medication indicated, . Medication will be administered in a safe and effective manner.8. Monitor for side effects or adverse drug reactions immediately after administrator and throughout each shift.13. Notify the attending physician and /or prescriber of: . c. Suspected adverse drug reactions. Record review of the Reference obtained from the internet on 10/12/23 from, How Rx ELIQUIS® (apixaban) Can Help | Safety Info (bmscustomerconnect.com) indicated, . ELIQUIS can cause bleeding, which can be serious, and rarely may lead to death. This is because ELIQUIS is a blood thinner medicine that reduces blood clotting. While taking ELIQUIS, you may bruise more easily and it may take longer than usual for any bleeding to stop. Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding when taking ELIQUIS: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 14 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0757 *unexpected bleeding or bleeding that lasts a long time, such as unusual bleeding from the Level of Harm - Minimal harm or potential for actual harm gums, nosebleeds that happen often, or menstrual or vaginal bleeding that is heavier than normal Residents Affected - Few *bleeding that is severe or you cannot control *red, pink, or brown urine; red or black stools (looks like tar) *coughing up or vomiting blood or vomit that looks like coffee grounds *unexpected pain, swelling, or joint pain *headaches, or feeling dizzy or weak FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 15 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 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 a medication error rate of less than 5 percent. There were 2 errors out of 32 opportunities, resulting in a 6.25% percent medication error involving 1 of 6 residents (Residents #37) reviewed for medication pass. Residents Affected - Some MA A failed to administer 2 scheduled doses of the medication Lyrica 50 mg (used to treat chronic pain) as ordered by the physician for Resident #37 on 11/13/23 beginning at 9:08 a.m. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life. Findings included: Record review of the face sheet dated indicated Resident #37 was an [AGE] year-old female admitted on [DATE] with diagnoses included muscle spasms. She was readmitted [DATE] with diagnoses of fractures of 3 thoracic vertebra (backbone to which ribs are attached and her left tibia (the larger of the 2 bones in the lower leg) after a fall. Record review of an admission MDS assessment dated [DATE] indicated Resident #37 had moderately impaired cognition with a BIMS (brief interview for mental status) score of 10 out of 15. Her pain interference with day-to-day activities was rarely or not at all and her worst pain was moderate pain level over the last 5 days. Record review of a care plan reviewed on 11/13/23 indicated Resident #37 was at risk for pain related to fractures and back spasms. Record review of the physician order summary dated November 2023 indicated Resident #37 was to receive Lyrica 50 mg 1 PO three times daily. During an observation and interview on 11/13/23 at 9:08 a.m., MA A prepared Resident #37's medications and said Resident #37 was out of Lyrica 50 mg. MA A walked to the medication room and looked for the resident's medication in the medication room. She said she ordered the medication last Thursday (11/09/23) and said the medication was not received . During an interview on 11/13/23 at 1:40 p.m., MA A said Resident #37's Lyrica medication was not received, the pharmacy sent the wrong medication. She said she was unable to give the 2nd dose of the scheduled dose of Lyrica 50 mg for the 2:00 p.m. dose. Record review of the MAR November 2023 for Resident #37 indicated she was to receive Lyrica 50 mg 1 PO three times daily; there was no indication the medications were administered by MA A on 11/13/23 at 9:00 a.m. and 2:00 p.m. During an interview on 11/13/23 at 3:00 p.m., the DON said the pharmacy sent the wrong medication today after the nurse called the pharmacy to reorder the Lyrica. The DON said she notified the physician of the 2 missed doses of Lyrica 50 mg for Resident #37. The DON said her expectations were for the staff to follow the policy for medications to be refilled timely and for the staff to have 3 days of medications on hand at all times. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 16 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 11/14/23 at 4:45 p.m., the Administrator said her expectation was for her staff to follow policy and procedures to prevent medication issues such as not having medications available. Record review of the facility's policy titled Ordering and Receiving Medication dated 08/2020 indicated Medications and related products are received on a timely basis.Reorder medications based on the estimated refill date on the pharmacy label or at least three days on hand in advance to ensure an adequate supply is on hand.- this is kind of a pharmacy tag. Event ID: Facility ID: 675602 If continuation sheet Page 17 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. Residents Affected - Many * The facility failed to ensure baking sheets did not have brown and/or black baked on build up and stacked together. * The facility failed to ensure muffin pans did not have brown baked on build up and stacked together. * The facility failed to ensure a scoop was not left in the bulk corn meal. * The facility failed to ensure the ice machine did not have a pink slimy substance in the drop chute. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations and interviews on 11/13/23, the following was noted in the kitchen: *at 08:35 a.m., on a storage shelf there were 3 small baking sheets with brown and/or black baked on residue were stacked together, 6 large baking sheets with brown and/or black baked on residue were stacked together, and 5 muffin pans with brown baked on residue were stacked together. The DM said she had difficulty getting the baked-on residue off of the baking sheets and the muffin pans. *at 08:40 a.m., in the dry pantry there was a bulk container of corn meal had a scoop inside container sitting on top of the corn meal. The DM said no scoops should be inside the bulk containers. *at 08:42 a.m., with the DM observing, this surveyor wiped the inside of the ice machine drop chute with a paper towel and a pink slimy substance was on the paper towel. The DM said she did not realize the ice machine had the pink slimy substance. She said the ice machine was cleaned at least monthly. The 2022 Food Code dated 01/18/23 indicated the following: 3-305.11 Food Storage Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to slash, dust or other contamination 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 18 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 Level of Harm - Minimal harm or potential for actual harm (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris Residents Affected - Many 4-602.11 Equipment Food-Contact Surfaces and Utensils. (E) Except when dry cleaning methods are used as specified under 4-603.11, surfaces of Utensils and Equipment contacting food that is not Time/Temperature Control for Safety Food shall be cleaned: (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 19 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2023 for 2 of 4 quarters reviewed for payroll data information. (Quarter 1 and Quarter 4) The facility failed to submit accurate staffing information to CMS for the 1st and 4th quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record Review of the facility's Civil Rights form (3761) dated 11/13/23 indicated the following: -6 RNs -9 LVNs -23 Direct Care Staff -6 Dietary -4 Housekeeping & Laundry -8 All Others Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 1 2023 (October 1- December 31), dated 11/08/2023, indicated the following entries: 1.Excessively Low Weekend Staffing Triggered .Triggered = Submitted Weekend Staffing data is excessively low. 2.Failed to have Licensed Nursing Coverage 24 Hours/Day . Triggered .Triggered = Four or More Days Within the Quarter <24 Hours/Day Licensed Nursing Staff Coverage. Infraction dates included: 10/8 (Saturday), 10/12 (Wednesday), 10/15 (Saturday), 10/16 (Sunday), 10/19 (Wednesday), 10/22 (Saturday), 10/23 (Sunday), 10/28 (Friday), 10/30 (Sunday) 11/01 (Tuesday), 11/02 (Wednesday), 11/10 (Thursday), 11/12 (Saturday), 11/13 (Sunday), 11/19 (Saturday), 11/20 (Sunday), 11/25 (Friday), 11/26 (Saturday), 11/27 (Sunday), 11/28 (Monday), 11/30 Wednesday) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 20 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0851 12/02 (Friday), 12/03 (Saturday), 12/04 (Sunday), 12/05 (Monday), 12/07 (Wednesday) Level of Harm - Minimal harm or potential for actual harm Record review of facility direct care time sheets and agency time sheets indicated the following staffing data during the first quarter: Residents Affected - Many -6:00 a.m. to 6:00 p.m. shift = 1 LVN and 4 CNAs -6:00 p.m. to 6:00 a.m. shift = 1 LVN and 3 CNAs -And 8 hours of RN coverage 8 hours/day. During an interview on 11/15/23 at 10:15 a.m., the Administrator said the 1st Quarter PBJ reports were submitted by the accounting department at the corporate office and all hours were not accurately captured and reported due to an error with the payroll system. It failed to include agency staffing or salaried employees in the reported hours. Record review of the CMS PBJ Staffing Data Report (payroll-based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 4 2023 (July 1- September 30), dated 11/08/2023, indicated the following entry: No RN Hours . Triggered . Triggered = Four or More Days Within the Quarter with no RN hours. Infraction dates included: 07/04 (Monday), 07/16 (Saturday) 09/09 (Friday), 09/16 (Friday). Record review of the interim DON's electronic medical record logins for facility Interim DON indicated he worked 8 hours on 07/04/23, 07/16/23, 09/09/23, and 09/16/23. During an interview on 11/15/23 at 10:15 a.m., the Administrator stated salary staff were mistakenly left off the PBJ hours reported by corporate. She said the facility followed the CMS Electronic Staffing Data Submission Payroll-Based Journal for Long-Term Care Facility Policy Manual as their policy for submitting PBJ data. The CMS Electronic Staffing Data Submission Payroll-Based Journal for Long-Term Care Facility Policy Manual indicated in part .Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 21 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0880 Provide and implement an infection prevention and control program. 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 maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 for 5 residents (Resident #3) reviewed for infection control during medication pass. Residents Affected - Few The facility failed to ensure MA A did not touch medications with her bare hand on 11/13/23 at 9:50 a.m. This failure could place residents at risk for the spread of infection and cross contamination. Findings included: Record review of Resident #3's face sheet dated 11/14/23 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (disease in which immune system damages protective covering of the nerves), fibromyalgia (widespread muscle pain and tenderness), and chronic migraine (moderate to severe and intense headache which happens more than half of a month for 3 months). Record review of Resident #3's annual MDS assessment, dated 10/12/23, indicated a BIMS score of 15 out of 15, which indicated no cognitive impairment. Record review of Resident #3's, undated, care plan indicated the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to a fracture of his arm and terminal multiple sclerosis. Record review of the physician order summary for November 2023 indicated Resident #3's received 20 pills or capsules at 9:00 a.m. medication pass. During an observation of medication pass on 11/13/23 at 9:50 a.m., MA A performed hygiene then MA A and placed Resident #3's medications into medication cup from touching the blister packets and bottles. MA A placed the medications on a clean tissue,without hand hygiene and started counting them, touching the pills with her bare hands as she placed them back into the medication cup. During an interview on 11/14/23 at 11:00 a.m., MA A said she got nervous and touched Resident #3's pills, but she should have used gloves to prevent possible cross-contamination. During an interview on 11/14/23 at 2:45 p.m., the DON said a resident's medication/pills should not be touched with a bare hand. She said gloves were to be used to prevent cross contamination. During an interview on 11/14/23 at 4:45 p.m., the Administrator said she expected her staff to follow policy and procedures to use gloves to prevent spreading germs or not having medications available. Record review of the facility's policy dated 10/25/22 titled Infection Control indicated This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675602 If continuation sheet Page 22 of 23 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 675602 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care of Gilmer 623 Hwy 155n Gilmer, TX 75644 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete infections. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Record review of the facility's policy dated 08/2020 titled Administration Procedures for All Medications indicated . 3. Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, . Event ID: Facility ID: 675602 If continuation sheet Page 23 of 23