Inspection·September 25, 2023

E0100, Potential Indicators of Psychosis, A. Hallucinations, was checked. Resident required one-person (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 14 Event ID: 675849 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 0655 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few physical assist with bed mobility, dressing, and toileting. Resident required two-person physical assist with transferring. Record review of CR #1's orders, dated 09/19/2023, reflected in part .behavior monitoring for: depression medication: Remeron, Order Date 09/12/2023 . Mirtazapine Tablet 30 mg, Give 1 tablet by mouth one time a day for depression, Order Date 09/12/2023 . Quetiapine Fumarate 25 mg Tablet, Give 1 tablet by mouth two times a day for antipsychotic, Order Date 09/13/2023 .and Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg (Quetiapine Fumarate), Give 1 tablet by mouth one time a day for antipsychotic . Record review of CR #1's Baseline Care Plan, dated 09/13/2023, revealed it did not reflect CR #1's history of hallucinations, history of depression, need for behavior monitoring for depression medication, and/or behavioral interventions to prevent suicidal attempts. Further review revealed Section 4., Social Services, Section C., was incomplete. Section C. included mental health needs, behavioral concerns, intervention suggestions to de-escalate situations, and depression screening. Record review of CR #1's Care Plan, dated 09/14/2023, revealed it did not reflect CR #1's needs for use of an antidepressant medication, behavior monitoring r/t antidepressant medication for depression, use of an antipsychotic medication, history of hallucinations, and/or history of depression. Record review of CR #1's Care Conference Summary notes, dated 09/14/2023, read in part .resident had history of anti-depressants .history of hallucinations .level of confusion is higher . Record review of CR #1's Progress Notes, effective date 09/16/2023, read in part Called to [CR #1's] room by charge nurse .[CR #1] lying in bed .blood covered over body and left arm .skin and fatty tissue hanging from left arm .Found in [CR #1's] right hand holing glass from picture frame in which [CR #1] stated he cut his wrist .Left forearm noted large laceration with tissue and skin cut out to left forearm and wrist area. Tendon and bone exposed to forearm approximately 12 x 9 x 0.7 cm . [CR #1] stated that the staff was trying to kill him, and he was trying to kill himself first before the staff did. [CR #1] was experiencing visual hallucinations but able to respond to questions appropriately . [CR #1] .kept stating they trying to kill me during the time with patient until EMS arrived . [CR #1] transported to [hospital]. In an interview on 09/19/2023 at 11:58 a.m., the Director of Clinical Operations/Director of Nursing (DCO/DON) said she had been working at the facility approximately since April 2023. She said CR #1 was at the facility for approximately 3-4 days. She said different team members from different departments (nursing, social services, activities, and dietary) were responsible for completing their section of the baseline care plan. She said each team member signed off on their section and once signed, the RN signed. She said CR #1 did not have any mental health diagnoses at the time of his admission and his PASRR did not indicate a mental illness. She said the resident was admitted from the hospital with orders for an antidepressant (Mirtazapine) and antipsychotic (Seroquel). She said baseline care plans were to be completed within 48-hours of admission. She said the facility also had 48-72 hours to complete medication diagnosis and list of disease processes. She said in-house behavior monitoring orders for depression medication were put into place for residents who were on an antidepressant. She said she was not aware CR #1 had a history of hallucinations until after his suicidal attempt and investigation. She said she learned about the hallucinations from the Director of Resident Support Services/Social Worker (DRSS/SW). She said CR #1 did not display any alarming behaviors prior to the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 2 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 0655 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few In an interview on 09/19/2023 at 2:27 p.m., the DRSS/SW said she had been working at the facility approximately since April 2022. She said it took her time to complete the baseline care plan because it took her a period to obtain the full scope of the resident's needs. She said she met with CR #1's family member on 09/11/2023. She said she asked the family member twice if CR #1 had any suicidal ideations and the family member told her no. She said the family member told her the resident had a history of hallucinations. She said she asked about CR #1's hallucinations, but the family member did not give her any details. She said she attempted to meet with the resident on the day he was admitted , but he was in therapy. She said CR #1 showed no signs of hallucinations and/or homicidal or suicidal ideations. She said the resident's Care Conference was held on 09/14/2023 with the IDT and two of CR #1's family members. In a follow-up interview on 09/20/2023 at 1:33 p.m., DRSS/SW she said she was not sure when her part of the baseline care plan should be completed. She said she received training on baseline care plans but did not recall by whom. She said the purpose of a baseline care plan was for it to include purposeful information about the resident, and it helped create a plan of care. She said she did not complete the Social Services section of the baseline care plan. She said the depression screening was not completed. She said the baseline care plan was opened but she was unable to complete her section because she had other facility duties (talking to families, talking to residents, giving updates to the families to address any questions, resolving concerns with other residents and families, NOMNCS, meetings, and discharges) that limited her from being able to complete her portion. She said to her knowledge, the history of the resident's hallucinations was relayed to the DCO/DON and nursing staff. She said the MDS Nurse communicated the information to the nursing staff. In a follow-up interview on 09/20/2023 at 12:29 p.m., the DRSS/SW said she had never known her not completing her section of the baseline care plan could affect a resident while she had been in her role as a DRSS/SW. She said she was not sure how it would affect the resident if it were not completed timely and/or if it was completed inaccurately. Record review of the facility's policy titled Comprehensive Care Plan, effective and revised 01/20/2021, read in part . Policy Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . The Administrator was notified on 09/20/2023 at 5:15 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on 09/21/2023 at 4:41 p.m. and included: PLAN OF REMOVAL Name of facility: [] Date: Sept. 20th, 2023 Immediate action: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 3 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 0655

F655 Level of Harm - Immediate jeopardy to resident health or safety -Director of Clinical Operations initiated in service on Baseline care plans per facility policy on 9/20/23 with the Interdisciplinary team. In-service covered completion of baseline care plan within 48 of admission, ensuring all disciplines complete their sections, and ensure interventions are in place for any behaviors, mental health, or psychosocial issues are identified. Inservice to be complete by 9/21/23. Residents Affected - Few -The Director of Clinical Operations completed an audit on baseline care plans. Random selection of baseline care plans was checked for accuracy and completion. Random selection was based off residents admitted within the last 30 days because comprehensive care plans are due by 21st day of admission. Audit of baseline care plans completed on 9/20/23 identified baseline care plan meetings occur within the 48 hours timeframe according to policy and procedure or a comprehensive care plan was in place for residents residing in community longer than 14 days. -Inservice RNs on ensuring that baseline care plan was complete prior to signing and locking; DCO initiated by 9/20/23 and completed by 9/21/23. -Director of Clinical Operations in serviced all Interdisciplinary Team on completion of Baseline Care plans within 48 hours of admission on [DATE]. -All new Admissions will be reviewed during morning standup meeting to ensure the baseline care plan are completed within 48 hours of admission and signed by all members of the inter disciplinary team. -Medical Director notified of alleged facility noncompliance with completion of baseline care plans on 9/20/23. -Resident #1 was discharged to the hospital on 9/16/2023 and has not returned to the facility and no updates since discharge. Discharge MDS indicates return is anticipated. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 09/22/2023 through 09/23/2023. Monitoring of the POR included: In an interview on 09/22/2023 at 2:50 p.m., the Administrator said she received baseline care plan in-service training. She said she made sure the baseline care plan was completed within 48-hours of admission and that all sections were completed so they could be closed in a timely manner. She said the IDT were to bring their computers to the morning meeting the day after a resident admits. She said if a resident admits to the facility late Friday through Sunday, the baseline care plan was completed no later than Monday morning at 11 a.m. In a follow-up interview on 09/22/2023 at 3:21 p.m., the Administrator said she and the DCO/DON completed the baseline care plan audit for last 30 days of admission. She said once the audit was completed, she got with the MDS Nurse to make sure those residents that had incomplete baseline care plans had a completed comprehensive care plan in the system. In an interview on 09/22/2023 at 2:26 p.m., the DCO/DON said the in-service training she provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 4 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 0655 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few covered the importance of completing the baseline care plan, timeline for completion, and the inclusion of accurate information. She said IDT were to bring their computers to the daily morning meetings to facilitate the signatures being completed before the morning meeting ended. She said the baseline care plan had to be completed along with signatures within 24-hours. She said every discipline must complete their section of the baseline care plan. She said interventions needed to meet the needs of the residents and had to be followed through. She said it was determined that residents who were at the facility for longer than 14 days had their comprehensive care plans completed. She said RNs were trained to open the baseline care plans upon admission and to leave it open until all information and signatures were entered, but no later than 48-hours. She said the medical director was notified of the alleged noncompliance. In an interview on 09/22/2023 at 3:33 p.m., the Assistant Director of Clinical Operations/Assistant Director of Nursing (ADCO/ADON) said she received in-service training. She said the training covered baseline care plans. She said they talked about completing the baseline care plans within 48-hours of a resident's admission. She said if the resident was residing in the facility for more than 14-days, they needed to have a comprehensive care plan completed. She said all disciplines must be completed and interventions such as mental health, psychosocial, and any behaviors had to be documented on the baseline care plan and the comprehensive care plan. In an interview on 09/23/2023 at 5:44 a.m., Nurse C said he had been working at the facility for 19 years. He said he worked the 10:00 p.m. to 6:00 a.m. Shift. He said he received in-service training. He said they discussed baseline care plans, and the time frame to complete them. He said they had to be completed within 48-hours. He said the baseline care plan was started by the nurse who started the resident's admission and other parts were completed by the other designated departments. In an interview on 09/23/2023 at 12:48 p.m., the DRSS/SW said she received in-service training. She said the plan put into place was for them to bring their laptops to the morning meetings so they could review the baseline care plans to ensure they were able to review and complete the plan. She said if a resident were to admit late Friday through Sunday, the goal was to have the baseline care plans completed by Monday morning by 11:00 a.m. She said the timeframe to have the baseline care plan completed was 48-hours within admission. In a follow-up interview on 09/23/2023 at 1:12 p.m., Nurse A said she worked the 2:00 p.m. to 10 p.m. shift. She said she received in-service training over baseline care plans. She said baseline care plans had to be initiated and completed within 48-hours of admission. She said nursing staff was responsible for completing some of the sections. Record review of the facility's audit findings for comprehensive care plans for admissions in the past 30 days revealed there were 11 new admits, all who had comprehensive care plans completed. Record review of the facility's in-service training records related to baseline care plans and behavior monitoring, dated 09/20/2023 and 09/21/2023, confirmed a total of 61 staff members were trained over behavior monitoring and/or baseline care plans. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was removed on 09/23/2023 at 1:19 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 5 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 interviews and records reviewed, the facility failed to ensure resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (CR #1) of 5 residents reviewed for accident hazards and supervision. -The facility failed to provide adequate supervision for CR #1 to prevent harm from suicidal ideations and self-injurious behaviors that resulted in him cutting his arm and wrist with broken glass and being hospitalized . -The facility failed to care plan and put interventions in place for CR#1 when he admitted to the facility with history of hallucinations, need for behavioral monitoring for depression, and behavioral interventions to prevent suicidal attempts resulting in CR#1 cutting his arm and wrist. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was removed on 09/23/2023 at 1:19 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure place residents at risk of not having their needs met, serious physical harm, injury, and/or death. The findings included: Record review of CR #1's admission Record, dated 09/19/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on 09/16/2023 to the hospital. Resident's diagnoses included cardiac arrest (cessation of normal circulation of blood due to failure of the heart to pump effectively), cognitive communication deficit (difficulties with thinking and how someone uses language), muscle weakness, abnormalities of gait and mobility (walking), lack of coordination, need for assistance with personal care, Hodgkin lymphoma (type of cancer that affects the lymphatic system), and type 2 diabetes mellitus (high blood sugar) with hypoglycemia (low blood sugar) without coma. Record review of CR #1's hospital admission paperwork, dated 08/11/2023, revealed CR #1's medical problems included visual hallucinations. Further review revealed discharged medications, dated 09/12/2023, included Mirtazapine 30 mg daily and Quetiapine 50 mg, take 1 tablet by mouth once daily in the morning for 90 days Record review of CR #1's admission MDS assessment, dated 09/15/2023, revealed Section C, Cognitive Patterns, C0500, BIMS Summary Score was in progress. Further review revealed Section E, Behavior,

E0100, Potential Indicators of Psychosis, A. Hallucinations, was checked. Resident required one-person physical assist with bed mobility, dressing, and toileting. Resident required two-person physical assist with transferring. Record review of CR #1's orders, dated 09/19/2023, reflected in part .behavior monitoring for: depression medication: Remeron, Order Date 09/12/2023 . Mirtazapine Tablet 30 mg, Give 1 tablet by mouth one time a day for depression, Order Date 09/12/2023 . Quetiapine Fumarate 25 mg Tablet, Give 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 6 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 tablet by mouth two times a day for antipsychotic, Order Date 09/13/2023 .and Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg (Quetiapine Fumarate), Give 1 tablet by mouth one time a day for antipsychotic . Record review of CR #1's Baseline Care Plan, dated 09/13/2023, revealed it did not reflect CR #1's history of hallucinations, history of depression, need for behavior monitoring for depression medication, and/or behavioral interventions to prevent suicidal attempts. Further review revealed Section 4., Social Services, Section C., was incomplete. Section C. included mental health needs, behavioral concerns, intervention suggestions to de-escalate situations, and depression screening. Record review of CR #1's Care Plan, dated 09/14/2023, revealed it did not reflect CR #1's needs for use of an antidepressant medication, behavior monitoring r/t antidepressant medication for depression, use of an antipsychotic medication, history of hallucinations, and/or history of depression. Record review of CR #1's Care Conference Summary notes, dated 09/14/2023, read in part .resident had history of anti-depressants .history of hallucinations .level of confusion is higher . Record review of CR #1's Progress Notes, effective date 09/16/2023, read in part Called to [CR #1's] room by charge nurse .[CR #1] lying in bed .blood covered over body and left arm .skin and fatty tissue hanging from left arm .Found in [CR #1's] right hand holing glass from picture frame in which [CR #1] stated he cut his wrist .Left forearm noted large laceration with tissue and skin cut out to left forearm and wrist area. Tendon and bone exposed to forearm approximately 12 x 9 x 0.7 cm . [CR #1] stated that the staff was trying to kill him, and he was trying to kill himself first before the staff did. [CR #1] was experiencing visual hallucinations but able to respond to questions appropriately . [CR #1] .kept stating they trying to kill me during the time with patient until EMS arrived . [CR #1] transported to [hospital]. In a telephone interview on 09/19/2023 at 3:05 p.m., CNA A said she had been working at the facility for approximately 1 year and 5 months. She said she worked the 6:00 a.m. to 6:00 p.m. shift the day of resident CR #1's incidents on 09/16/2023. She said the resident was kind of mobile. She said he could stand-up but needed one-person assistance. She said he was responsive to incontinence care. She said that was the first time she had worked with the resident. She said prior to the resident's 2nd incident, the resident was lying in bed and appeared to be sleeping. She said the resident did not appear to be depressed and did not display any suicidal ideations. She said she was passing out lunch trays when he cut himself. She said she observed the wound care nurse applying pressure to his arm. She said CR #1 kept saying y'all are not going to kill me. She said she did not know who he was referring to. In a telephone interview on 09/19/2023 at 3:17 p.m., CNA B said she had been working at the facility for approximately 1 year. She said she worked the 6:00 a.m. to 6:00 p.m. shift the day of CR #1's incidents on 09/16/2023. She said she had not worked with the resident prior to 09/16/2023. She said she was working in hall 300 when she heard a boom, like books falling. She said when she went inside CR #1's room, she found him on the floor, leaning up against the wall, in a sitting position, on the side of the bed that was located beside the window. She said she called out to Nurse A, and they helped the resident off the floor and moved him to bed A. She said when they were helping him up from the floor and back onto the other bed, he said they were trying to kill him. She said Nurse A assessed the resident, put his bed in the lowest position, covered him up, and everyone left the room. She said incident #1, when CR #1 was found on his bedroom floor, happened approximately 15 to 20 minutes before CR #1 cut himself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 7 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 In a telephone interview on 09/19/2023 at 3:47 p.m., Nurse B said she had been working at the facility for approximately 11 months. She said she worked the 6:00 a.m. to 6:00 p.m. shift the day of CR #1's incident. She said she worked hall 300. She said it was the first time she worked with the resident. She said she saw CR #1 approximately 2 or more times during her rounds. She said when she first saw the resident, he was asleep in his bed and during another round he was lying in bed with his eyes open. She said throughout the day, the resident was calm and did not express that he wanted to hurt himself. She said he did not show signs of hallucinations or suicidal ideations. She said she was the one who found the resident when he cut his arm and wrist. She said the resident was lying in bed and was cutting himself with glass from a broken picture frame. She said CR #1 said staff were trying to kill him with medications, but he was going to kill himself first. In a telephone interview on 09/19/2023 at 4:41 p.m., Nurse A said she was headed toward the lounge when CNAs B and A were passing by CR #1's room and called her. She said she was assigned to a different hall that day but was the closest nurse at that time. She said when she got to the resident's room, he was sitting on the floor by his bed, on the side that was near the window. She said she assessed the resident and asked him what happened. She said the resident told her that he sat too close to the edge of the bed and slid down to the floor. She said CNAs B, A, and herself helped the resident to bed B and then moved him to bed A because bed B still had some movement to it when it was in the locked position. She said the resident told her one time that someone was trying to kill him. She said she sat on the bed with him, told him no one was trying to kill him, and talked with him for a little while. She said the CNAs left the room to pass meal trays and she left to go report the incident. She said when she was on her way to report the incident to Nurse B, she got called away to hall 400. She said by the time she finished in hall 400, CR #1 had already cut himself. She said she did not complete an incident report for the unwitnessed fall or report the resident's hallucinations to the DCO/DON and/or ADCO/ADON because she got busy doing something else. She said per the facility's policy, she should have completed an incident report. In a follow-up telephone interview on 09/19/2023 at 5:30 p.m., CNA A said CR #1 had an unwitnessed fall prior to cutting himself. She said CNA B found him in his room approximately 20 minutes before he cut himself. She said CNA B came down the hallway and told her and Nurse A that she heard a bang in another resident's room. She said CNA B told them she found CR #1 on the floor, in a sitting position, closest to the window that was near the left of the air conditioner. She said Nurse A, CNA B, and she picked CR #1 up, laid him on his bed and Nurse A assessed him and took his vitals. CNA A said CR #1 was moved to A bed because something was wrong with his bed (B bed). She said when CR #1 was on the floor he said once that y'all trying to kill me. CNA A said she did not mention what CR #1 said to anyone. She said after the incident, the resident was put back into bed, and she left and passed out lunch trays. In a follow-up interview on 09/19/2023 at 4:59 p.m., the DCO/DON said CR #1 had a fall and Nurse A forgot to complete an incident report. In a follow-up interview on 09/20/2023 at 2:33 p.m., the DCO/DON, said she was not aware of CR #1's history of hallucinations until the incident occurred. In a follow-up telephone interview on 09/20/2023 at 2:59 p.m., CNA B she said she did not remember if she asked CR #1 any follow-up questions. She said the resident was not upset, crying, or in distress after his fall. She said he only made the comment once. She said she was never told that the resident had a history of hallucinations. She said the resident was not hers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 8 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 In a follow-up telephone interview on 09/20/2023 at 3:04 p.m., CNA A said she did not ask CR #1 any follow-up questions. She said the resident showed no emotion and was his regular self. She said he was quiet and only made the one comment. She said she was never told about his history of hallucinations. She said he showed no signs of suicidal ideations. She said CR #1 was not her regular resident. In a follow-up interview on 09/20/2023 at 3:50 p.m., the MDS Nurse said the CNAs knew what behaviors to monitor because it was in the residents' Point of Care located under Monitor-Behavior Symptoms in their computer system. She said the Charge Nurses told the CNAs about any behavior problems with residents. She said CNAs also gave reports to the oncoming shift CNAs. In a follow-up interview on 09/20/2023 at 4:15 p.m., Nurse A said she asked CR #1 who was trying to kill him, and he said staff. She said when she asked him what staff, he did not answer. She said the resident did not show any signs of distress. She said the resident was not crying or upset. She said she was never told he had a history of hallucinations. She said he did not show any signs of homicidal or suicidal ideations. She said incident reports should be documented in the computer system under risk management. She said she was not exactly sure what the policy said but incidents should be documented within an hour. Record review of the facility's policy titled Incident and Accident effective 03/01/2017, read in part . Policy Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations. Procedure 1. Licensed nurse will complete an incident and accident report when staff is aware that an incident occurred . 2. Incident reports are located in the electronic health record and are completed electronically. 3. Licensed nurse will complete a fall investigation report after every fall . 4. Licensed nurse will .and update resident's care plan after each fall. 5. Director of Clinical Operations will request a medication review by the pharmacist if new meds have been started . 6. Social Services will assess resident for any psycho-social changes related to the Incident or Accident . The Administrator was notified on 09/20/2023 at 5:15 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at that time. The facility's Plan of Removal was accepted on 09/21/2023 at 4:41 p.m. and included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 9 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 PLAN OF REMOVAL Level of Harm - Immediate jeopardy to resident health or safety Name of facility: [] Residents Affected - Few Immediate action: Date: Sept. 20th, 2023

F689-The Director of Nurses completed Inservice initiated Inservice on 9/20/23 with nursing staff. The in service covered assessing residents for behaviors, completion of behavior monitoring sheet on residents with psychotropic medications requiring monitoring and assuring interventions are identified. In-service reads behavior monitoring, hallucinations, aggressive behavior, verbal aggression notify DCO, Charge Nurse, and/or Administrator. Assessment and properly assessing residents, act on assessment and notify management immediately, initiate 1:1 with the notification of delusion and hallucination. Staff are to follow the interactive care path for symptoms of acute mental status change. Director of Clinical Service's in service will be completed by 9/21/23. Revisions to care plan for Resident # 1 cannot be made due to resident being transferred to the hospital after incident occurred. -The Director of Clinical Operations completed an audit of all residents' antipsychotic, Psychotropic medications to ensure behavior monitoring sheets and interventions are in place. The audit was conducted and completed on 9/20/23. -The Director of Clinical Operations and Designee Assessed all residents currently on antipsychotic, psychotropic medication with no notable signs of abnormal behavior on 9/20/2023. -Nurse A was in serviced on 9/20/2023 by Regional Director of Operations on timely completing I/A [incident/accident] documentation and to ensure monitoring and interventions are put in place and residents are place on monitoring and/or 1:1 if resident displaying signs of behavioral or psychosis with suicidal ideation until psychologist or psychiatrist can assess for safety. Employee must follow interact care path for symptoms of acute mental status change. -Medical Director notified of alleged facility noncompliance with completion of behavior monitoring with interventions on 9/20/23. -Staff to include Social Worker was in-serviced on 9/20/2023 by Regional Director of Resident Support on obtaining order and initiating psychological services for any resident displaying signs or having history of psychosis to include hallucinations. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 09/22/2023 through 09/23/2023. Monitoring of the POR included: In an interview on 09/22/2023 at 1:35 p.m., the DCO/DON, said she initiated and completed in-service training with staff from department heads all the way to dietary. She said the in-service for behavior monitoring, baseline care plans, assessing the residents for behaviors, and the directions on how to follow the care path symptoms of acute mental status change (tool used by RN's and LVN's that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 10 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 outlined what to do if a changed in a residents' mental status was identified) was reviewed and discussed. She said the in-service covered hallucinations, delusions, suicidal ideations, including if a resident reported that someone wanted to kill them or if the resident wanted to kill themselves, and verbal and physical aggression. She said staff were told to report any of those behaviors to the Charge Nurses, DCO/DON, and the Administrator. She said she told nursing staff to assess the resident immediately for any of the above-mentioned behaviors. She said Nurses were to follow the Care Path Symptoms of Acute Mental Status Change assessment tool. She said it gave a clinical path to initiate for a resident, ex. 1:1 supervision if suicidal ideations were voiced by the resident during the assessment and gave directions to notify the resident's MD, DCO/DON, and the Administrator. In the same interview, the DCO/DON said if a resident voiced suicidal ideations, hallucinations, delusions, verbal and/or physical aggressive behaviors to a CNA, the CNA was to implement behavior monitoring which included 1:1 supervision, were not to leave the resident alone, were to simultaneously notify the charge nurse over the assignment of the resident, DCO/DON, and the Administrator. She said the CNAs were to take the resident with them and/or use their cell phone to call the nurse and/or the Administrator for help. She said an audit was completed on 09/20/2023 of all residents' clinical records who were on an antipsychotic and/or psychotropic medication. She said the audit yielded that 100% of the residents that had a behavior monitoring in place listed behavior monitoring and the outcome of the monitoring in place. She said the behaviors listed to monitor for antidepressants included looking for behaviors such as crying, sadness, and tearfulness. She said they looked for antidepressants, antipsychotics, hypnotics, and antianxiety medications which warranted monitoring for listed exhibited behaviors. She said monitoring for the listed exhibited behaviors would be recorded on their online system under the LMAR behavior monitoring sheet. She said there were questions that were prompted for the charge nurses, LVNs and/or RNs, to monitor residents for behaviors that included antidepressants, antipsychotics, and hypnotics. She said there was an action to relieve the behavior that was being exhibited and an outcome to note if the action was effective. She said the ADCO/ADON completed the behavior monitoring audit on 09/20/2023. She said an audit for psychotropic medications was also completed by the ADCO/ADON and herself. She said the ADCO/ADON, and she also completed verbal assessments on all residents at the facility, including those that were taking antipsychotics and psychotropic medications. She said the ADCO/ADON, and she made rounds throughout the facility and asked those residents how they were doing. She said they asked the residents how they felt and whether they felt safe. In an interview on 09/22/2023 at 2:50 p.m., the Administrator said she received in-service training over the behavior monitoring process, mental status pathway (care path for mental health) and initiating psychiatric consults when a resident said anything that was out of the norm. In the same interview, she said she received training over the behavior monitoring process for resident's identified with behavior concerns. She said residents who displayed behavior concerns were not to be left alone. She said if the resident was bedridden, the staff member was to stay with them and was to use their cell phone to call the nurse on duty, the DCO/DON, ADCO/ADON, and/or herself. She said If the resident was wheelchair bound and/or ambulatory, staff were to assist the resident to the nurse/nurse's station so the nurse could complete an assessment. She said in case the CNAs heard the resident make any comments or display any behaviors such as saying they wanted to kill themselves, cause harm to others, or displayed any aggressive behaviors, including verbal and physical aggression, and/or any type of hallucinations, she said the assessment process included the nurse taking vitals, notifying the residents' physician, the medical director, and starting a psychiatric services consultation. She said the in-service training also covered the care path assessment tool. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 11 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 when these types of behaviors were displayed, the tool gave nurses a guide on how to respond as far as documentation, who to notify, and covered the different steps to take. She said the assessment tool was an additional resource for the nurses to use. She said their Medical Director was notified of the alleged non-compliance on 09/20/2023 by telephone and text message. She said the Regional Director of Resident Support and the RVP were emailed. She said the email included what the in-service needed to cover with the Director of Resident Support Services. She said the in-service covered if a resident displayed psychiatric issues, when family members reported any psychiatric issues, and when to refer residents to psychiatric services. She said some examples and reasons to refer to psychiatric services were also included. In an interview on 09/22/2023 at 3:33 p.m., the ADCO/ADON said she received in-service training. She said assessments on all residents were conducted verbally. She said the DOC/DON and she went to each residents' rooms and talked to them. She said they made sure their needs were being met, asked them if they felt safe, and asked them if they were experiencing hallucinations. She said they had an interactive care path tool that they followed/used. She said if the residents showed signs/symptoms of any acute mental health status changes they were to notify the DCO/DON. She said the interactive care path provided guidance and gave them a path on what to do based on what behaviors the resident was displaying. In a follow-up interview on 9/22/2023 at 3:48 p.m., the ADCO/ADON said the DCO/DON and she took the team lead and assisted with the audit on psychotropic medications. She said she found that the residents who were on those medications had their behavior monitoring orders in place. She said she helped complete in person rounds on the residents. She said she received training on how to complete the behavior monitoring sheet (LMAR) in their computer system. She said the behavior monitoring sheets were completed upon a resident's admission. She said during admission, residents were assessed, and medications were reviewed for antidepressants. She said residents that took psychotropic medications were flagged and the order(s) would be entered into the facility's computer system. She said the nurses completed the behavior monitoring sheets. She said 1:1 would be initiated, the DCO/DON would be notified and/or the Administrator if behavior concerns arose. In an interview on 09/22/2023 at 4:02 p.m., Nurse D said she worked the 3:00 p.m. to 10:00 p.m. shift. She said she received in-service training that talked about behavior monitoring and residents that had different ideations such as if someone wanted to kill them and/or if the resident planned and/or talked about wanting to harm themselves. She said she would inform the DCO/DON, Administrator, and doctor. She said she would put behavior monitoring in place. She said she would have someone sit with the resident or have them sit by the nurse's station where everyone could see them. She said there was guidance that could be used if there was a change in condition. She said the assessment tool included checking the resident's vitals to see if anything was abnormal and reporting to the doctor. She said she would consider the resident's baseline and would look for anything that deviated from their baseline. She said she would also look at their medication orders to see if it was a contributing factor to their behavior change. In an interview on 09/22/2023 at 4:21 p.m., CNA C said she had been working at the facility approximately since 2021. She said she worked the 6:00 a.m. to 6:00 p.m. shift. She said she received in-service training over behavior monitoring. She said if she noticed any behavior concerns, she had to document them in the computer system and would tell the Nurse, DCO/DON, and/or the Administrator. She said if the resident was suicidal, she would stay with the resident, provide 1:1 monitoring, and would call the Nurse, DCO/DON, and/or Administrator. She said anytime a resident had signs of hallucinations they must take the above steps because it was a serious matter. She said behavior problems (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 12 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 should be documented on the resident's POC (Point of Care). She said the nurses assessed the residents if there was a change in the residents' mental status. In an interview on 09/23/2023 at 12:48 p.m., the DRSS/SW said she received in-service training. She said they discussed the different reasons to refer residents to psychiatric services, such as trauma, if their sleep pattern changed, if they had agitation, were anxious, or experienced isolation. She said residents who were prescribed psychotropic medications was also a reason to refer for services. She said they talked about steps moving forward such as what to do to minimize the likelihood of this happening again. She said she also received training over the care path assessment tool. She said if a resident had any mental health status changes and/or symptoms, the tool outlined what steps to take. She said it was an interact care path that was ultimately a map to be followed if a resident were to have any new mental status changes. She said it would guide staff step by step if a behavior was being displayed and what next steps were to be taken. In an interview on 09/23/2023 at 5:44 a.m., Nurse C said he had been working at the facility for 19 years. He said he worked the 10:00 p.m. to 6:00 a.m. Shift. He said he received the behavior monitoring training and received the Care Path assessment sheet that covered what to do and how to assess the resident for behavior abnormalities. He said the tool covered who to notify, such as the facility's DCO/DON, MD, Administrator, and ultimately the resident's family. He said they discussed aggressive behaviors such as if a resident wanted to kill themselves, falls, depression, and altered mental status such as hallucinations and suicidal ideations. He said anytime residents took antipsychotic medications, they put behavior monitors in the computer system and every day they checked off whether any behaviors were present such as yelling, hollering, crying, and/or aggression. He said residents with suicidal ideations had to be monitored, could not be left alone, and must be placed on 1:1 supervision. In an interview on 09/23/2023 at 5:55 a.m., CNA D said she had been working at the facility for approximately 1 month. She said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she received in-service training regarding behavior monitoring. She said if a resident was acting suicidal or threatening, she would let the Nurse, DCO/DON, and Administrator know. She said residents were not to be left alone. She said if the resident was unable to leave the room, she would stay with them and use her telephone to call for help. She said they must also document the behavior in their online computer system. In an interview on 09/23/2023 at 6:38 a.m., CNA E said she worked the 6:00 a.m. to 6:00 p.m. shift. She said she received training over behavior monitoring. She said residents who displayed any type of behavior concerns needed to be reported to the Nurse, DCO/DON, and the Administrator immediately. She said the training covered behaviors such as hallucinations, yelling, kicking, screaming, and suicidal ideations. She said once those behaviors occurred, they should not be brushed aside. She said they were to provide 1:1 monitoring, stay with the resident, never leave them alone, and call for help. She said the types of behaviors listed above must also be recorded in their online computer system under behavior symptoms. She said the system also asked if the displayed behaviors were new or ongoing. She said if she was not sure about something and/or a procedure, she would report to the nurse. In an interview on 09/23/2023 at 6:52 a.m., CMA A said she had been working at the facility for approximately 1 year. She said she worked the 6:00 a.m. to 2:00 p.m. shift. She said she received training over behavior monitoring. She said if a resident had behavior concerns or expressed that they were going to kill themselves or someone, the CNAs needed to report it to the charge nurse, DCO/DON, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 13 of 14 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 675849 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Burnet Bay 3921 N Main Baytown, TX 77521 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 and/or Administrator. She said if the resident showed signs of suicidal ideations, the resident was to not be left alone. She said the resident was to be taken to the nurse's station. She said if the resident was bedridden and unable to be taken to the nurse's station, she would stay in the room with the resident to provide 1:1 monitoring and would call for help using her cellular phone. She said the in-service training also covered when residents showed signs of hallucinations. She said she was a medication aide and would notify the charge nurse, DCO/DON, and administration. She said the CNAs would need to document the occurrence in the computer system, but in her case, she would notify administration who would be responsible for documenting. In a follow-up interview on 09/23/2023 at 1:12 p.m., Nurse A said she worked the 2:00 p.m. to 10:00 p.m. shift on the weekends. She said she received in-service training over behavior monitoring and assessing the residents for change in mental status, and documenting changes in their behavior in their computer system. She said the behavior monitoring training covered behaviors such as aggression, physical, verbal and what to do when a resident showed signs of suicidal ideations. She said residents who indicated they wanted to hurt themselves or others were never to be left alone. She said the DCO/DON, Administrator and resident's physician were all to be notified immediately if residents displayed those behaviors. She said psychiatric services should also be notified. She said they went over the Care Path tool to use for guidance when such behaviors were being displayed and a handout was provided. She said the tool provided steps to take when a mental status change was detected in a resident. She said it included taking vital signs and notifying all required personnel and their family immediately. She said the in-service training went over assessing residents' mental status. She said residents who took antipsychotic medications are monitored for behaviors and was documented in their online computer system to track any changes to their baseline status. Record review of the facility's behavior monitoring audit findings were reviewed. The findings revealed the audits for behavior monitoring, comprehensive care plans, and medication class were completed and were entered in the facility's computer system. Record review of the Care Path assessment sheet/tool was completed. The assessment/tool was a flow chart that separated the ordered steps to take when a resident displayed new symptoms of an acute mental status change. Ordered steps included: noting an acute status change in the resident, taking vitals, evaluating symptoms and signs, and evaluating results; considering contacting the physician for further evaluation and management, ordering and evaluating test results, managing the resident's behavior in the facility, and/or monitoring the resident's response. Record review of the facility's in-service training records related to the Care Path assessment/tool, dated 09/20/2023, confirmed 61 facility staff members received training over behavior[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 14 of 14