Health inspection·October 8, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few possible triggers in her environment. Date Initiated: 11/14/2019. A care plan to address Resident #1's impaired cognitive function or impaired thought processes r/t ANOXIC BRAIN INJURY. SHE has cognitive loss (loss of memory, time sense and requires assistance with decision making r/t Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression. Date Initiated: 05/07/2020. Revision on: 05/07/2020. Resident #1 will improve current level of cognitive function through the review date. Date Initiated: 02/09/2021. Revision on: 09/12/2025. Target Date: 10/19/2025.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Skills for Daily Decision Making (section C1000) were coded at 3, indicating her cognition was severely impaired. Resident #1 was coded to require substantial/maximal assistance with ADLs. She was always incontinent of bowels and bladder and used a wheelchair for mobility.Record review of Resident #1's physician orders dated September 2025 revealed orders with a start date of 9/25/25 to administer Emtricitabine- Tenofovir oral tablet 200-300 MG (Emtricitabine- Tenofovir Disoproxil Fumarate) Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC) Give 1 tablet by mouth one time only for contraceptive for 1 day with a start date of 9/24/25. Record review of Resident #1's MAR dated September 2025 revealed that Resident #1 was administered Emtricitabine and tenofovir antiretroviral medication (used to treat and prevent HIV infection) on 9/25/25 through 9/30/25. Resident #1 was administered Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral on 9/25/25 through 9/30/25. Resident #1 was administered Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC (Oral Contraceptive) 1 tablet by mouth on 9/25/25.Record review of Nurses Note dated 9/23/2025. Note Text: Called to room by CNA A and CNA B reported to staff nurses that resident was having sexual activity with Resident #1. Resident #1 was immediately removed for safety. When male resident questioned by staff nurse what happened male resident began to laugh and stated nothing happened . Female resident is not cognitively intact female resident monitored all safety measures in place. Male resident immediately monitored 1-1 by staff. DON notified of above. MD notified. Family notified by DON awaiting return call. The resident transferred to local hospital.Record review of Nurses Note dated 9/23/2025. Note Text: Spoke with forensic nurse at local hospital who reported that she completed an exam on resident . She stated she was able to get a swab for DNA and STD testing but was unable to do a vaginal exam because the resident closed her legs and would not allow her to examine her. She stated that a pregnancy test was performed and was negative, resident was treated prophylactically with ATBs and will discharge to facility with orders for ATBs to continue. Resident #1 will also return with an order for Plan B . Nurse stated that an official report will be available in 1-2 business days. Called RP to update her on report from the nurse, message left, awaiting call back.Record review of the post hospital discharge instructions and orders dated 9/24/25 revealed that Resident #1 was seen for sexual assault. A SANE (Sexual Assault Nurse Examiner) adult sexual assault exam was performed (a forensic exam was performed (results pending and coordinated with the local police department). Orders for STI Sexually Transmitted Infection Prophylaxis: Ondansetron 4 mg PO x1, Azithromycin 1gm PO x1, Metronidazole 2gms PO x1, Ceftriaxone 500mg IM reconstituted with 1.1 ml of 1% Lidocaine. Lab orders for Pharyngeal Gonorrhea ( a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae bacteria that infects the pharynx. It is spread through oral sex with an infected person and can be asymptomatic, but symptoms may include a sore throat, difficulty swallowing, swollen lymph nodes in the neck, or redness/swelling in the throat) and Chlamydia (a common sexually transmitted infection (STI) caused by the bacterium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 2 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Chlamydia trachomatis. It is primarily spread through sexual contact with an infected person).Record review of Nurse Practitioner note dated 9/25/25 for Resident #1: Chief Complaint: Evaluation of patient for alleged sexual assault incident: Hospital Course: She was taken to the ER a few days ago after an incident with another resident of a sexual nature. She was examined for possible sexual assault and started on post-exposure prophylaxis (levonorgestrel single dose; dolutegravir 50 mg daily x28 days; emtricitabine/tenofovir 200/300 mg daily x28 days; PRN ondansetron). Hospital examination results are pending. Today she appears in no distress. History of Present Illness: Resident #1, a [AGE] years old female with history of anoxic brain damage, epilepsy, unsteadiness on the feet, ataxia (poor muscle control that causes clumsy movements), abnormal gait, generalized muscle weakness, dysphagia (swallowing difficulties), mixed receptive/expressive language disorder (is a neurodevelopmental condition that affects a child's ability to both understand and produce language), dysarthria (difficulty speaking because the muscles you use for speech are weak), severe hypoxic ischemic encephalopathy (a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), hypertensive heart disease (a constellation of structural and functional changes in the left ventricle, left atrium, and coronary arteries resulting from chronic blood pressure elevation), and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormone) among other medical problems was seen today upon the request of the Nurse due to a reportable incident that happened between patient and another resident. Patient was examined in the dining room. She is nonverbal and not able to make needs known due to anoxic brain injury. Patient was taken to the ER a few days ago for an examination of an encounter with another resident of a sexual nature. She was examined for sexual assault. Findings were not available at the time of this visit; however, patient was placed on several medications including: Levonorgestrel 1.5 mg tablet 1 time only, dolutegravir 50 mg daily for 28 days, emtricitabine/tenofovir 200/300 mg daily for 28 days and as needed Zofran. The results of the patient's examination at the hospital are still pending. Additional consultations: Psychiatry and Psychology evaluations requested for psychological support.Record Review of Resident #1's Diagnostic Assessment from Psychological Evaluation and Treatment Services dated 9/29/25 revealed that the referral was made due to possible sexual assault at the facility. Resident #1 was unable to answer assessment questions or questions regarding the alleged events therefore she is not a candidate for psychotherapy. Record review of Resident #1's Initial Psychiatric assessment dated [DATE] revealed that Resident #1 was referred due to recent sexual assault without ability to consent, patient was noted to not be able to respond, trauma screening was unable to be determined due to patient being unable to respond. Resident #2Record review of Resident #2's facility admission record dated 10/2/25 revealed a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (a stroke damaged the right side of the brain, causing paralysis (hemiplegia) and/or weakness (hemiparesis) on the left side of the body) and Chronic Viral Hepatitis C (a long-term liver infection caused by the hepatitis C virus). Record review of Resident #2's care plan revealed care plans to address areas that included: The resident has a behavior problem r/t inappropriate verbal sexual comments towards staff. Date Initiated: 08/18/2025. Revision on: 09/23/2025 Goals: The resident will have fewer episodes of inappropriate behaviors by review date. Date Initiated: 08/18/2025 Revision on: 09/23/2025 Target Date: 12/18/2025: Interventions: The resident's behavior is de-escalated by redirection. Date Initiated: 08/18/2025. Revision on: 09/23/2025. Medication adjustment by psych Date Initiated: 10/01/2025. Minimize potential for the resident's disruptive behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 3 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Date Initiated: 08/18/2025. Revision on: 09/23/2025, Psych consult date initiated: 08/18/2025. A care plan area to address the potential to be physically aggressive r/t Dementia Date Initiated: 09/09/2025. Revision on: 09/24/2025 and a care plan to address uses antidepressant medication r/t Depression. Date Initiated: 06/20/2025. Revision on: 09/24/2025. Interventions included to Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT, Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Date Initiated: 06/20/2025.Record review Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15, indicating he was moderately cognitively impaired. The complete MDS was requested but not received.Record review of Resident #2's physician orders for September 2025 for Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) give 2 tablet by mouth two times a day for mood with a start date of 9/26/25, and a Physician order dated 10/2/25 for Chlamydia and Gonorrhea.Record review of Resident #2's MAR dated September 2025 revealed that Resident #2 was administered Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) on 9/26/25 at 9:00 am and on 9/27 through 9/30 at 9:00 AM and 6 PM. Record Review of Resident #2's lab results dated 10/3/25 for Chlamydia and Gonorrhea revealed they were negative. Record review of lab results dated 10/4/ 25 revealed an abnormal and reactive result to the Hepatitis C Antibody (positive for Hepatitis C).Record review of Resident #2's Psychological Services Progress note dated 9/24/25 read in part.Clinician was notified that this patient was accused of sexually assaulting another resident and requested a crisis session. The clinician worked on developing a therapeutic relationship with the patient as he was new to her. Used supportive listening to validate patient's emotions and encouraged patient to tell their story Related to current difficulties and then focused more narrowly to intervene. Patient's Response to Intervention: Patient reported frustration and stated that a CNA accused him of raping another resident last night. He reported that the resident is frequently in his room because it used to be her room.Clinician then asked him to explain the events of last night. He stated that she was in his room watching TV and wet her clothes. He opened the door to the bathroom for her. She then wheeled to the support bar straight ahead and stood up holding onto the bar. He moved her wheelchair to the side so that he could help her get on the toilet. He acknowledged that her pants and brief were off but denied that his had been pulled down. He reported that he has helped her in the bathroom previously and that CNAs have had to come and assist in the past. He further reportedfrustration about being accused of rape. The clinician stated that if it was consensual there was not issue. He immediately stated that the other resident was not capable of consent, and he was not sure she was even at a five-year-old's level of understanding. Next, he reported the police taking his statement, clothing, and brief as evidence. He reported understanding the collection due to the allegation.Record review of Nurse Practitioner Progress note for Resident #2, dated 9/25/25 read in part.Patient, [AGE] years old male was seen today in his room due to incident involving another resident. According to resident, he was accused of having sex with another resident. Patient is now on one-on-one supervision and is wondering why he is on surveillance. According to the Resident, the female resident wanders into his room and bathroom all the time and he denies doing what he is accused of. However, according to the Nurse and Director of Nursing, there were eyewitnesses who saw what happened. Law enforcement is now involved, and patent {sic} has been made aware of that. Patent was made aware that he will continue to be on close supervision by staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 4 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few until Law enforcement are done with their investigation. Verbalized understanding. Patient is alert during this assessment and was able to answer all questions appropriately. Patient has history of dementia but is still able to hold normal conversations. Psychological and psychiatric consultation requested. Will continue one-on-one supervision with this patient until incident is resolved.Record review of Resident #2's Psychiatric Subsequent Assessment/note dated 9/30/25 read in part.Reason for Referral: Sexually Inappropriate Behavior, Other: Alleged sexual assault of another resident. Patient seen today for a F/U visit. The last visit was on 9/26/2025. Initiated Depakote 250 mg tablet BID. Assess the Pt's behaviors, monitor the response to Depakote. ON EXAM, the Pt is in the room, w/ 1:1 staff, calm and not in distress. LAST visit: Per nursing staff, [Resident #1] was wandering to [Resident #2's] room on 9/23/25 and the Aid {sic} witnessed inappropriate behavior in [Resident #2's] bathroom. In addition, the Aid {sic} witnessed that [Resident #1] was facing the wall and [Resident #2] was behind her. [Resident #2] was placed to 1:1. [Resident #1] was sent out to the hospital for vaginal examination, however the patient refused to cooperate.Record review of Resident #2's Social Service Note dated 10/1/25. Note: interviewed resident regarding his statement of assisting female residents to the bathroom when they come into his room. Initially in the interview he stated that on the night of the alleged abuse he was assisting the female resident to the bathroom. He also stated that he helped another female resident to the bathroom. As the interview continued, he stated that he assisted the female resident to the bathroom on the night in question, however that was the only female resident he assisted to the bathroom. When asked why he did not report this initially, he stated I did not remember. When asked what did he do with the other female resident he stated that they visit, have conversations on various topics, and watch a tv show together. Resident was educated that if a female resident comes into his room, he should press the call light or go to the Nurse's station to request the assistance of the Charge Nurse but never provide any form of ADL care. Resident verbalized understanding of the conversation.Record Review of Resident #2's Social Services Note dated 10/2/25. Note Text: Director of Social Services informed by IDT that it was determined that resident would be discharged to another facility for safety of the other residents. DRSS met with resident and informed him of impending discharge. He expressed understanding of situation and agreed with discharge. After discussing options, resident stated he would like to explore being admitted to a personal care home. Since resident is his own RP, DRSS inquired if he would like me to contact family members listed on his face sheet to inform them and he stated yes. Afterwards, DRSS contacted residents' families. They expressed understanding of situation and discharge.Record review of Nurse's Note for Resident #2 dated 10/4/2025. Note Text: Resident discharged to a personal care home. Transported out to vehicle via wheelchair. Resident left the facility awake, alert, oriented, without any c/o pain or signs of distress.During an interview on 10/01/25 at 9:56 a.m., the DON said LVN Q called around 8:50 p.m., on 09/23/25, and said CNA A and CNA B called LVN Q to Resident #2's bathroom after they saw Resident #1 and Resident #2 with their clothes pulled down and exposed. Resident #2 was standing behind Resident #1, and his semen was everywhere. The DON said Resident #1 wanders, and the intervention was to redirect, and the facility staff made rounds frequently. She said Resident #1 often wanders to Resident #2's room and to other residents' rooms, and staff would remove her from his room. The DON said Resident #1's BIMS was 0, and she could not consent to having sex. When the surveyor asked what other interventions were put in place after redirecting was ineffective, the DON responded that the facility did not place wandering residents on one-on-one. Still, staff made frequent rounds to check on residents. The DON said Resident #2 was making sexual comments towards staff, but he had not had any physical sexual act until this incident. The DON said Resident #2 denied having (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 5 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few any sexual act with Resident #1.During an observation and interview on 10/01/25 at 11:12 a.m., Resident #1 was dressed in her street clothes and was sitting in her wheelchair in the TV room. Resident #1 did not respond to the surveyor's greeting, and she was not able to make her needs known.During an interview on 10/01/25 at 11:18 a.m., Resident #2 said he did not have sex with Resident #1, but he was assisting her to the toilet, and she fell backward, and he had to hold onto her. Resident #2 said the day of the incident was not the first time he had taken Resident #2 to the bathroom and assisted her to the toilet, because Resident #1 often comes to his room, and the staff were aware she comes to his room. He denied having sexual intercourse and said he had not ejaculated in months, and nothing sexual happened.During an interview on 10/01/25 at 2:44 p.m., CNA A said she and CNA B went to Resident #2's room, and the entrance door to Resident #2's room was closed. CNA A said she knocked on Resident #2's room entrance door and announced herself before she opened the room door, and she saw Resident #2 was having sex with Resident #1. CNA A said she shouted what are doing and Resident #2 pulled his penis out of Resident #1 and there was semen coming out of his penis. Then she told CNA B to call LVN Q. CNA A said that Resident #1 and Resident #2 were laughing, and Resident #2 said he was assisting her to the toilet. CNA A said she told Resident #2 to go back to his room, waited for LVN Q, and when she came and assessed Resident #1, she told her to take Resident #1 to her room and not clean her, and she was going to call the DON and the Administrator. CNA A said the police came and took the brief, which had urine and bowel movement. CNA A said she placed a clean incontinent brief on Resident #1 but did not clean her. CNA A said the police officer interviewed her, and she wrote her statement for the incident.During an interview on 10/02/25 at 8:22 a.m., CNA B said she and CNA A went to provide care to Resident #2, and when they got to his room, the entrance door was closed. CNA A knocked on the door, introduced herself, and opened the door, and she was behind her. CNA B said CNA A shouted What are you doing? and when she came from behind CNA A and looked, she saw Resident #2 had only an incontinent pull-up, and his brief was pulled down, and his penis was out, and he had semen everywhere, and he was laughing.During an interview on 10/02/25 at 9:19 a.m., NP said one of the Nurses called and told him CNA A and CNA B found Resident #1 and Resident #2 having a sexual encounter. NP said Resident #1 was sent to the hospital. NP said he made rounds the next day after the Nurse told him and saw and assessed both Resident #1 and Resident #2. NP said Resident #1 was nonverbal and she could not respond to any question or tell you anything and could not consent to consensual sex. NP said the hospital staff gave Resident #1 medication to prevent pregnancy and two types of HIV medication. The NP said Resident #2 denied having sex with Resident #1. NP said the facility staff had not told him Resident # 2 made any sexual comments to staff or to other residents. NP said it is a possibility if Resident #2 had hepatitis C and had unprotected sex with Resident #1, she could contract hepatitis C. He said he was unsure whether Resident #1 had hepatitis C.During a telephone interview on 10/02/25 at 9:41 a.m., FM said Resident #1 could not consent to sexual activity. RP said she would not consent for Resident #1 to have sexual relations at the facility. FM said the facility failed to protect Resident # 1 from sexual assault.During a telephone interview on 10/02/25 at 10:23 a.m., the Detective said he would be investigating the incident, but it has not been assigned to him yet; it would be assigned to him in a couple of days. He said from the report that the officers who came out to the facility read, CNA A said she observed Resident #1 and Resident #2 having sexual intercourse. He said the Forensic Nurse did a sexual assault kit when Resident #1 was in the hospital, and it would take 4 to 6 weeks before the result would be ready.During an interview on 10/02/25 at 12:12 p.m., the DON said she was not aware Resident #2 had hepatitis C, and the NP would see Resident #1 and Resident #2 today, and he would order labs on Resident #2. The DON said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 6 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 could be infected with hepatitis C, and she would follow up with the NP.During an interview on 10/02/25 at 2:28 p.m., the Administrator said he was responsible for in-service training on abuse and neglect. He said the abuse policy was part of the admission paper. The DON, the Corporate Nurse, and the Administrator said they do not have any policy on how to educate the resident about safe consensual sex, but they would contact their corporate office.During an interview on 10/02/25 at 2:43 p.m., the Interim Administrator said he had been the interim at the facility for three weeks, did not have access to the facility computer, and could not recall when he was notified about the incident between Resident #1 and Resident #2. He said he was not aware that the facility had a policy on how residents would be educated on having safe consensual sex. He said they usually made rounds every two hours for residents and wandering residents, and if two hours were not safe for a wandering resident, the resident should be in a locked unit. The Interim Administrator said with regard to sexual abuse in service for the staff, they were educated to separate the residents and notify the Abuse Coordinator. He said it would be an awkward conversation with residents on consensual sex. He said his thoughts about any resident who wanted to be intimate would go to the Nurse or Social Worker, who would advise the resident on what to do.During an interview on 10/02/25 at 1:45 p.m., NP said he saw Resident #1 and Resident #2 today (10/02/25), and they are stable, and labs were ordered: HIV, hepatitis C profile, BMP, and CBC for Resident #2. He said he advised the facility to find another placement for Resident #2 after the investigation because the facility still has other female residents, which could prevent the incident from recurring. He said the facility should have involved Resident #1 in activities to occupy her time and put her to bed early to rest, which would have prevented her wandering, and the incident could have been prevented. Record review of the facility policy and procedure entitled Abuse dated last revised 1/1/23 read in part.The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement.Abuse is the willful infliction of injury or negligent, unreasonable confinement.resulting in physical or emotional harm or pain to a resident; or sexual abuse involuntary or nonconsensual sexual conduct that would constitute an offense under penal code S 21.08 (indecent exposure) or Penal Code chapter 22 (assaultive offenses) sexual harassment, sexual coercion or sexual assault.Residents will not be subjected to abuse by anyone including, but not limited to, community staff, other residents.This includes physical, verbal, sexual, physical/chemical restraint. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m.The following Plan of Removal submitted by the facility was accepted on 10/03/2025 at 1:46 p.m.Plan of Removal F600 October 2, 2025.What corrective actions have been implemented for the identified residents? Plan of Removal.Immediate Jeopardy On 10/2/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safetyThe facility failed to ensure Resident #1 was free from sexual abuse.F600 - Sexual abuse Immediate action Resident #1 sent to hospital for assessment and returned on 9/24/25. Resident placed on one on one 10/2/25 until alternative placement is found on secure unit. Family notified 10/2/2025 of plan for discharge Resident #1 was placed on 1:1 monitoring until alternate placement is found due to wandering into other resident's rooms. Alternate placement will be a secure unit or placement chosen by RP. The Regional director of clinical services (RDCO) in-serviced the Executive Director of operations (administrator) and Director of Nursing operation (DON) on abuse policy on 10/2/2025. The DON initiated In-service on Abuse and Neglect for all staff on 10/2/2025 to be completed on 10/3/2025. Residents #1 and #2 were assessed by charge Nurses on 10/2/2025, no concern noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 7 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed on 10/2/2025, and no concern noted. Resident #2 was placed on 1:1 monitoring until evaluated by psychiatrist for further direction on care. Resident #2 RP was notified of resident current status by social worker on 10/2/2025. Resident # 2 physicians was notified of current status by DCO on 10/2/2025. Resident #1 and #2 care plans were updated by MDS Nurse on 10/2/2025. DON trained all staff on rounding and supervision on residents to be completed on 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025.Identification of Residents Affected or Likely to be AffectedOn 10/2/2025 the DON and Social worker completed the audit for all residents who wander to other residents' room, none was identified. An audit was completed on 10/2/2025Facility's Plan to ensure compliance quickly DON will provide in-service to all staff on abuse policy and will be completed on 10/3/2025. Staff will not provide direct care until training is completed. DON will provide training for all staff on redirecting resident that wanders into other resident's room and to notify the charge Nurse immediately. DON trained Charge Nurse to assess the residents, notify the DON and Administrator and to monitor residents. Training to be completed on 10/3/2025. DCO will review residents that wander daily in IDT meetings to determine changes to where they wander to and determine if they need to revise their plan of care. Daily rounds will be conducted by the IDT during focus rounds to identify any concern with residents that wanders and discuss the concern with administrator. Social worker to contact resident #1 Rp to discuss plan of care to be completed 10/3/2025. The medical Director was notified of the immediate jeopardy on 10/2/2025 by the administrator. The medical director reviewed abuse and neglect policy and made no changes to the policy on 10/2/2025. Any staff member not available for training will not assume any job assignment until training is completed. Staff will identify residents with inappropriate behaviors such as sexual comments, wandering that poses a safety concern, or aggression. If a resident experiences inappropriate behaviors we immediately place them on a 1:1. Psych is then consulted to provide guidance on the behavior and to assist with a plan of care. IDT will ensure that proper interventions are in place. DCO and/or designee will communicate with staff. DCO and/or designee will monitor process. Monitoring of the plan of removal from 10/04/2025 through10/06/25 included:Record review of P Event ID: Facility ID: 675848 If continuation sheet Page 8 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision.- The facility failed to ensure Resident #1 who was severely cognitively impaired and nonverbal and Resident #2 who was moderately cognitively impaired and had behaviors of inappropriate sexual comments to staff received adequate supervision to prevent abuse after she wandered into Resident #2's room in facility on 9/23/25. Resident #1 was sexually assaulted by Resident #2. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.This deficiency exposed residents living in the facility to potential harm, injury, or death due to not being adequately monitored. Record review of Resident #1's facility admission record dated 10/1/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with most current admission date of 6/26/18. Resident #1 admitted with diagnoses that included anoxic brain damage (a condition where the brain experiences a complete lack of oxygen supply. This deprivation of oxygen can lead to widespread damage to brain cells, resulting in severe neurological impairment or death) and epilepsy and epileptic syndromes (Epilepsy is a brain disorder characterized by recurrent, unprovoked seizures, while an epileptic syndrome is a specific, complex constellation of signs and symptoms that define a unique epilepsy condition. An epileptic syndrome includes specific seizure types, other clinical features).Record review of Residents #1's care plan date Initiated 9/15/21 and revised on 9/24/25 revealed she was care-planned for a high elopement risk/wandering in male residents' room and was at risk for possible injury r/t impaired safety awareness and diagnosis of dementia, Anoxic brain damage. Date Initiated: 09/15/2021. Revision on: 09/24/2025: Goals: Resident #1's safety will be maintained throughout the review date. Date Initiated: 09/15/2021. Revision on: 09/12/2025. Target Date: 10/19/2025 Interventions: Assess for fall risk. Date Initiated: 09/15/2021. Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures, and memory boxes. Date Initiated: 09/15/2021. Wander guard placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. Staff to monitor daily. Date Initiated: 09/15/2021. Redirect resident. Date Initiated: 09/24/2025. A care plan to address Resident #1 identifies as a trauma survivor. 1.possible trigger of aggressive vocal stimuli. 2. Childhood trauma memories, Domestic abuse memories , Physical Abuse memories, Sexual Abuse memories. Date Initiated: 11/14/2019. Revision on: 05/07/2020. Goals: SHE will remain stable and adjusted to her environment. Date Initiated: 11/14/2019 Revision on: 09/12/2025. Target Date: 10/19/2025. Interventions: Ask for permission to enter resident's room, perform care, and/or assist with ADLs. Date Initiated: 09/08/2023. Explain all procedures to the resident before starting and allow the resident (X minutes) to adjust to changes when necessary. Date Initiated: 09/08/2023. Reduction of possible triggers in her environment. Date Initiated: 11/14/2019. A care plan to address Resident #1's impaired cognitive function or impaired thought processes r/t ANOXIC BRAIN INJURY. SHE has cognitive loss (loss of memory, time sense and requires assistance with decision making r/t Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression. Date Initiated: 05/07/2020. Revision on: 05/07/2020. Resident #1 will improve current level of cognitive function through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 9 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the review date. Date Initiated: 02/09/2021. Revision on: 09/12/2025. Target Date: 10/19/2025.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Skills for Daily Decision Making (section C1000) were coded at 3, indicating her cognition was severely impaired. Resident #1 was coded to require substantial/maximal assistance with ADLs. She was always incontinent of bowels and bladder and used a wheelchair for mobility.Record review of Resident #1's physician orders dated September 2025 revealed orders with a start date of 9/25/25 to administer Emtricitabine- Tenofovir oral tablet 200-300 MG (Emtricitabine- Tenofovir Disoproxil Fumarate) Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC) Give 1 tablet by mouth one time only for contraceptive for 1 day with a start date of 9/24/25. Record review of Resident #1's MAR dated September 2025 revealed that Resident #1 was administered Emtricitabine and tenofovir antiretroviral medication (used to treat and prevent HIV infection) on 9/25/25 through 9/30/25. Resident #1 was administered Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral on 9/25/25 through 9/30/25. Resident #1 was administered Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC (Oral Contraceptive) 1 tablet by mouth on 9/25/25.Record review of Nurses Note dated 9/23/2025. Note Text: Called to room by CNA A and CNA B reported to staff nurses that resident was having sexual activity with Resident #1. Resident #1 was immediately removed for safety. When male resident questioned by staff nurse what happened male resident began to laugh and stated nothing happened . Female resident is not cognitively intact female resident monitored all safety measures in place. Male resident immediately monitored 1-1 by staff. DON notified of above. MD notified. Family notified by DON awaiting return call. The resident transferred to local hospital.Record review of Nurses Note dated 9/23/2025. Note Text: Spoke with forensic nurse at local hospital who reported that she completed an exam on resident . She stated she was able to get a swab for DNA and STD testing but was unable to do a vaginal exam because the resident closed her legs and would not allow her to examine her. She stated that a pregnancy test was performed and was negative, resident was treated prophylactically with ATBs and will discharge to facility with orders for ATBs to continue. Resident #1 will also return with an order for Plan B . Nurse stated that an official report will be available in 1-2 business days. Called RP to update her on report from the nurse, message left, awaiting call back.Record review of the post hospital discharge instructions and orders dated 9/24/25 revealed that Resident #1 was seen for sexual assault. A SANE (Sexual Assault Nurse Examiner) adult sexual assault exam was performed (a forensic exam was performed (results pending and coordinated with the local police department). Orders for STI Sexually Transmitted Infection Prophylaxis: Ondansetron 4 mg PO x1, Azithromycin 1gm PO x1, Metronidazole 2gms PO x1, Ceftriaxone 500mg IM reconstituted with 1.1 ml of 1% Lidocaine. Lab orders for Pharyngeal Gonorrhea ( a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae bacteria that infects the pharynx. It is spread through oral sex with an infected person and can be asymptomatic, but symptoms may include a sore throat, difficulty swallowing, swollen lymph nodes in the neck, or redness/swelling in the throat) and Chlamydia (a common sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. It is primarily spread through sexual contact with an infected person).Record review of Nurse Practitioner note dated 9/25/25 for Resident #1: Chief Complaint: Evaluation of patient for alleged sexual assault incident: Hospital Course: She was taken to the ER a few days ago after an incident with another resident of a sexual nature. She was examined for possible sexual assault and started on post-exposure prophylaxis (levonorgestrel single dose; dolutegravir 50 mg daily x28 days; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 10 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few emtricitabine/tenofovir 200/300 mg daily x28 days; PRN ondansetron). Hospital examination results are pending. Today she appears in no distress. History of Present Illness: Resident #1, a [AGE] years old female with history of anoxic brain damage, epilepsy, unsteadiness on the feet, ataxia (poor muscle control that causes clumsy movements), abnormal gait, generalized muscle weakness, dysphagia (swallowing difficulties), mixed receptive/expressive language disorder (is a neurodevelopmental condition that affects a child's ability to both understand and produce language), dysarthria (difficulty speaking because the muscles you use for speech are weak), severe hypoxic ischemic encephalopathy (a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), hypertensive heart disease (a constellation of structural and functional changes in the left ventricle, left atrium, and coronary arteries resulting from chronic blood pressure elevation), and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormone) among other medical problems was seen today upon the request of the Nurse due to a reportable incident that happened between patient and another resident. Patient was examined in the dining room. She is nonverbal and not able to make needs known due to anoxic brain injury. Patient was taken to the ER a few days ago for an examination of an encounter with another resident of a sexual nature. She was examined for sexual assault. Findings were not available at the time of this visit; however, patient was placed on several medications including: Levonorgestrel 1.5 mg tablet 1 time only, dolutegravir 50 mg daily for 28 days, emtricitabine/tenofovir 200/300 mg daily for 28 days and as needed Zofran. The results of the patient's examination at the hospital are still pending. Additional consultations: Psychiatry and Psychology evaluations requested for psychological support.Record Review of Resident #1's Diagnostic Assessment from Psychological Evaluation and Treatment Services dated 9/29/25 revealed that the referral was made due to possible sexual assault at the facility. Resident #1 was unable to answer assessment questions or questions regarding the alleged events therefore she is not a candidate for psychotherapy. Record review of Resident #1's Initial Psychiatric assessment dated [DATE] revealed that Resident #1 was referred due to recent sexual assault without ability to consent, patient was noted to not be able to respond, trauma screening was unable to be determined due to patient being unable to respond. Resident #2Record review of Resident #2's facility admission record dated 10/2/25 revealed a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (a stroke damaged the right side of the brain, causing paralysis (hemiplegia) and/or weakness (hemiparesis) on the left side of the body) and Chronic Viral Hepatitis C (a long-term liver infection caused by the hepatitis C virus). Record review of Resident #2's care plan revealed care plans to address areas that included: The resident has a behavior problem r/t inappropriate verbal sexual comments towards staff. Date Initiated: 08/18/2025. Revision on: 09/23/2025 Goals: The resident will have fewer episodes of inappropriate behaviors by review date. Date Initiated: 08/18/2025 Revision on: 09/23/2025 Target Date: 12/18/2025: Interventions: The resident's behavior is de-escalated by redirection. Date Initiated: 08/18/2025. Revision on: 09/23/2025. Medication adjustment by psych Date Initiated: 10/01/2025. Minimize potential for the resident's disruptive behaviors. Date Initiated: 08/18/2025. Revision on: 09/23/2025, Psych consult date initiated: 08/18/2025. A care plan area to address the potential to be physically aggressive r/t Dementia Date Initiated: 09/09/2025. Revision on: 09/24/2025 and a care plan to address uses antidepressant medication r/t Depression. Date Initiated: 06/20/2025. Revision on: 09/24/2025. Interventions included to Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 11 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Date Initiated: 06/20/2025.Record review Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15, indicating he was moderately cognitively impaired. The complete MDS was requested but not received.Record review of Resident #2's physician orders for September 2025 for Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) give 2 tablet by mouth two times a day for mood with a start date of 9/26/25, and a Physician order dated 10/2/25 for Chlamydia and Gonorrhea.Record review of Resident #2's MAR dated September 2025 revealed that Resident #2 was administered Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) on 9/26/25 at 9:00 am and on 9/27 through 9/30 at 9:00 AM and 6 PM. Record Review of Resident #2's lab results dated 10/3/25 for Chlamydia and Gonorrhea revealed they were negative. Record review of lab results dated 10/4/ 25 revealed an abnormal and reactive result to the Hepatitis C Antibody (positive for Hepatitis C).Record review of Resident #2's Psychological Services Progress note dated 9/24/25 read in part.Clinician was notified that this patient was accused of sexually assaulting another resident and requested a crisis session. The clinician worked on developing a therapeutic relationship with the patient as he was new to her. Used supportive listening to validate patient's emotions and encouraged patient to tell their story Related to current difficulties and then focused more narrowly to intervene. Patient's Response to Intervention: Patient reported frustration and stated that a CNA accused him of raping another resident last night. He reported that the resident is frequently in his room because it used to be her room.Clinician then asked him to explain the events of last night. He stated that she was in his room watching TV and wet her clothes. He opened the door to the bathroom for her. She then wheeled to the support bar straight ahead and stood up holding onto the bar. He moved her wheelchair to the side so that he could help her get on the toilet. He acknowledged that her pants and brief were off but denied that his had been pulled down. He reported that he has helped her in the bathroom previously and that CNAs have had to come and assist in the past. He further reportedfrustration about being accused of rape. The clinician stated that if it was consensual there was not issue. He immediately stated that the other resident was not capable of consent, and he was not sure she was even at a five-year-old's level of understanding. Next, he reported the police taking his statement, clothing, and brief as evidence. He reported understanding the collection due to the allegation.Record review of Nurse Practitioner Progress note for Resident #2, dated 9/25/25 read in part.Patient, [AGE] years old male was seen today in his room due to incident involving another resident. According to resident, he was accused of having sex with another resident. Patient is now on one-on-one supervision and is wondering why he is on surveillance. According to the Resident, the female resident wanders into his room and bathroom all the time and he denies doing what he is accused of. However, according to the Nurse and Director of Nursing, there were eyewitnesses who saw what happened. Law enforcement is now involved, and patent {sic} has been made aware of that. Patent was made aware that he will continue to be on close supervision by staff until Law enforcement are done with their investigation. Verbalized understanding. Patient is alert during this assessment and was able to answer all questions appropriately. Patient has history of dementia but is still able to hold normal conversations. Psychological and psychiatric consultation requested. Will continue one-on-one supervision with this patient until incident is resolved.Record review of Resident #2's Psychiatric Subsequent Assessment/note dated 9/30/25 read in part.Reason for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 12 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Referral: Sexually Inappropriate Behavior, Other: Alleged sexual assault of another resident. Patient seen today for a F/U visit. The last visit was on 9/26/2025. Initiated Depakote 250 mg tablet BID. Assess the Pt's behaviors, monitor the response to Depakote. ON EXAM, the Pt is in the room, w/ 1:1 staff, calm and not in distress. LAST visit: Per nursing staff, [Resident #1] was wandering to [Resident #2's] room on 9/23/25 and the Aid {sic} witnessed inappropriate behavior in [Resident #2's] bathroom. In addition, the Aid {sic} witnessed that [Resident #1] was facing the wall and [Resident #2] was behind her. [Resident #2] was placed to 1:1. [Resident #1] was sent out to the hospital for vaginal examination, however the patient refused to cooperate.Record review of Resident #2's Social Service Note dated 10/1/25. Note: interviewed resident regarding his statement of assisting female residents to the bathroom when they come into his room. Initially in the interview he stated that on the night of the alleged abuse he was assisting the female resident to the bathroom. He also stated that he helped another female resident to the bathroom. As the interview continued, he stated that he assisted the female resident to the bathroom on the night in question, however that was the only female resident he assisted to the bathroom. When asked why he did not report this initially, he stated I did not remember. When asked what did he do with the other female resident he stated that they visit, have conversations on various topics, and watch a tv show together. Resident was educated that if a female resident comes into his room, he should press the call light or go to the Nurse's station to request the assistance of the Charge Nurse but never provide any form of ADL care. Resident verbalized understanding of the conversation.Record Review of Resident #2's Social Services Note dated 10/2/25. Note Text: Director of Social Services informed by IDT that it was determined that resident would be discharged to another facility for safety of the other residents. DRSS met with resident and informed him of impending discharge. He expressed understanding of situation and agreed with discharge. After discussing options, resident stated he would like to explore being admitted to a personal care home. Since resident is his own RP, DRSS inquired if he would like me to contact family members listed on his face sheet to inform them and he stated yes. Afterwards, DRSS contacted residents' families. They expressed understanding of situation and discharge.Record review of Nurse's Note for Resident #2 dated 10/4/2025. Note Text: Resident discharged to a personal care home. Transported out to vehicle via wheelchair. Resident left the facility awake, alert, oriented, without any c/o pain or signs of distress. During an interview on 10/01/25 at 9:56 a.m., the DON said LVN Q called around 8:50 p.m., on 09/23/25, and said CNA A and CNA B called LVN Q to Resident #2's bathroom after they saw Resident #1 and Resident #2 with their clothes pulled down and exposed. Resident #2 was standing behind Resident #1, and his semen was everywhere. The DON said Resident #1 wanders, and the intervention was to redirect, and the facility staff made rounds frequently. She said Resident #1 often wanders to Resident #2's room and to other residents' rooms, and staff would remove her from his room. The DON said Resident #1's BIMS was 0, and she could not consent to having sex. When the surveyor asked what other interventions were put in place after redirecting was ineffective, the DON responded that the facility did not place wandering residents on one-on-one. Still, staff made frequent rounds to check on residents. The DON said Resident #2 was making sexual comments towards staff, but he had not had any physical sexual act until this incident. The DON said Resident #2 denied having any sexual act with Resident #1.During an observation and interview on 10/01/25 at 11:12 a.m., Resident #1 was dressed in her street clothes and was sitting in her wheelchair in the TV room. Resident #1 did not respond to the surveyor's greeting, and she was not able to make her needs known.During an interview on 10/01/25 at 11:18 a.m., Resident #2 said he did not have sex with Resident #1, but he was assisting her to the toilet, and she fell backward, and he had to hold onto her. Resident #2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 13 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few said the day of the incident was not the first time he had taken Resident #2 to the bathroom and assisted her to the toilet, because Resident #1 often comes to his room, and the staff were aware she comes to his room. He denied having sexual intercourse and said he had not ejaculated in months, and nothing sexual happened.During an interview on 10/01/25 at 2:44 p.m., CNA A said she and CNA B went to Resident #2's room, and the entrance door to Resident #2's room was closed. CNA A said she knocked on Resident #2's room entrance door and announced herself before she opened the room door, and she saw Resident #2 was having sex with Resident #1. CNA A said she shouted what are doing and Resident #2 pulled his penis out of Resident #1 and there was semen coming out of his penis. Then she told CNA B to call LVN Q. CNA A said that Resident #1 and Resident #2 were laughing, and Resident #2 said he was assisting her to the toilet. CNA A said she told Resident #2 to go back to his room, waited for LVN Q, and when she came and assessed Resident #1, she told her to take Resident #1 to her room and not clean her, and she was going to call the DON and the Administrator. CNA A said the police came and took the brief, which had urine and bowel movement. CNA A said she placed a clean incontinent brief on Resident #1 but did not clean her. CNA A said the police officer interviewed her, and she wrote her statement for the incident.During an interview on 10/02/25 at 8:22 a.m., CNA B said she and CNA A went to provide care to Resident #2, and when they got to his room, the entrance door was closed. CNA A knocked on the door, introduced herself, and opened the door, and she was behind her. CNA B said CNA A shouted What are you doing? and when she came from behind CNA A and looked, she saw Resident #2 had only an incontinent pull-up, and his brief was pulled down, and his penis was out, and he had semen everywhere, and he was laughing.During an interview on 10/02/25 at 9:19 a.m., NP said one of the Nurses called and told him CNA A and CNA B found Resident #1 and Resident #2 having a sexual encounter. NP said Resident #1 was sent to the hospital. NP said he made rounds the next day after the Nurse told him, and saw and assessed both Resident #1 and Resident #2. NP said Resident #1 was nonverbal and she could not respond to any question or tell you anything, and could not consent to consensual sex. NP said the hospital staff gave Resident #1 medication to prevent pregnancy and two types of HIV medication. The NP said Resident #2 denied having sex with the resident. NP said the facility staff had not told him Resident # 2 made any sexual comments to staff or to other residents. NP said it is a possibility if Resident #2 had hepatitis C and had unprotected sex with Resident #1, she could contract hepatitis C. He said he was unsure whether Resident #1 had hepatitis C.During a telephone interview on 10/02/25 at 9:41 a.m., FM said Resident #1 could not consent to sexual activity. RP said she would not consent for Resident #1 to have sexual relations at the facility. FM said the facility failed to protect Resident # 1 from sexual assault.During a telephone interview on 10/02/25 at 10:23 a.m., the Detective said he would be investigating the incident, but it has not been assigned to him yet; it would be assigned to him in a couple of days. He said from the report that the officers who came out to the facility read, CNA A said she observed Resident #1 and Resident #2 having sexual intercourse. He said the Forensic Nurse did a sexual assault kit when Resident #1 was in the hospital, and it would take 4 to 6 weeks before the result would be ready.During an interview on 10/02/25 at 12:12 p.m., the DON said she was not aware Resident #2 had hepatitis C, and the NP would see Resident #1 and Resident #2 today, and he would order labs on Resident #2. The DON said Resident #1 could be infected with hepatitis C, and she would follow up with the NP.During an interview on 10/02/25 at 2:28 p.m., the Administrator said he was responsible for in-service training on abuse and neglect. He said the abuse policy was part of the admission paper. The DON, the Corporate Nurse, and the Administrator said they do not have any policy on how to educate the resident about safe consensual sex, but they would contact their corporate office.During an interview on 10/02/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 14 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 2:43 p.m., the Interim Administrator said he had been the interim at the facility for three weeks, did not have access to the facility computer, and could not recall when he was notified about the incident between Resident #1 and Resident #2. He said he was not aware that the facility had a policy on how residents would be educated on having safe consensual sex. He said they usually made rounds every two hours for residents and wandering residents, and if two hours were not safe for a wandering resident, the resident should be in a locked unit. The Interim Administrator said with regard to sexual abuse in service for the staff, they were educated to separate the residents and notify the Abuse Coordinator. He said it would be an awkward conversation with residents on consensual sex. He said his thoughts about any resident who wanted to be intimate would go to the Nurse or Social Worker, who would advise the resident on what to do.During an interview on 10/02/25 at 1:45 p.m., NP said he saw Resident #1 and Resident #2 today (10/02/25), and they are stable, and labs were ordered: HIV, hepatitis C profile, BMP, and CBC for Resident #2. He said he advised the facility to find another placement for Resident #2 after the investigation because the facility still has other female residents, which could prevent the incident from recurring. He said the facility should have involved Resident #1 in activities to occupy her time and put her to bed early to rest, which would have prevented her wandering, and the incident could have been prevented.Record review of the facility policy and procedure entitled Incident and Accident dated 3-1-17 read in part.Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations.Licensed nurse will complete an incident and accident report when staff is aware that an incident occurred. Review each incident report at daily clinical meeting.Licensed nurse will notify physician and responsible party and update resident's care plan.If resident requires one to one supervision, staff will document using the One-on-One Monitoring form.Record review of the facility policy and procedure entitled Elopement dated 11/01/2019, provided by facility DON who referred to this policy as the policy on wandering on 10/5/25 read in part. POLICY: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill will be held quarterly.Once it has been established that a patient/resident is missing, the following staff members are notified immediately: The charge nurse, Executive Director of Operations, Director of Clinical Operations, and social service designee, responsible party and the primary care physician. Conduct a headcount. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. F689- Accident and SupervisionThe following Plan of Removal submitted by the facility was accepted on 10/03/2025 at 1:46 p.m.Plan of Removal F689 October 2, 2025.What corrective actions have been implemented for the identified residents? Plan of Removal.Immediate Jeopardy On 10/2/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safetyThe facility failed to ensure Resident #1 received adequate supervision to prevent abuse.F689- Accident and SupervisionImmediate Action Resident #1 sent to hospital for assessment and returned on 9/24/25. Resident placed on one on one 10/2/25 until alternative placement is found on secure unit. Family notified 10/2/2025 of plan for discharge. Resident #1 was placed on 1:1 on 10/2/2025 until alternate placement is found due to wandering into other resident's rooms. Alternate placement will be a secure unit or placement chosen by RP. Resident #2 was placed on 1:1 on 10/2/2025 until evaluated by psychiatrist for further direction on care. Identification of Residents Affected or Likely to be Affected: On 10/2/2025 the DON and Social worker completed the audit for all residents who wander to other residents' room, none was identified. An audit was completed on 10/2/2025.Facility's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675848 If continuation sheet Page 15 of 16 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 675848 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Webster 17231 Mill Forest Webster, TX 77598 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Plan to ensure compliance quickly #2 will be re-evaluated by the Psychiatry by 10/3/2025. Resident #2 is appropriate for group home as determined by psych services. Referral to group home sent by Social Services on 10.3.25 per family recommendation. The Director of Nurses initiated Inservice on 10/2/25 with all staff. Inservice was on Abuse and neglect, resident rights, Accident and Supervision which was conducted by the Director of Clinical Service. Inservice will be completed by 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025. The Director of Clinical Operations and Designee Assessed all wandering residents to determine if they are wandering into other resident rooms and if they are at risk. Resident assessment completed on 10/3/2025, Social worker completed audit on 10/2/2025 on all residents for inappropriate sexual behavior and none was identified. Medical Director notified of alleged facility noncompliance with ensuring supervision of wandering staff. Reviewed staff training on Resident Abuse, Accident and Supervision on 10/2/2025. No changes with policy will be made at this time. Staff are required to make rounds every 2 hours to monitor and supervise residents. All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed on 10/2/2025, and no concern noted. Audit performed on 10.3.25 by Social Worker and DCO. No residents with inappropriate sexual behaviors were identified. Any staff member not available for training will not assume any job assignment until training is completed. All new hires will be educated on abuse policy, resident monitoring, and supervision. Ad Hoc QAPI completed to review all IJs, interventions and Plan of care taken with IDT and Medical director, all interventions are effective at this time.Mo Event ID: Facility ID: 675848 If continuation sheet Page 16 of 16