Inspection·December 13, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were responsible for accurately assessing and reporting resident conditions through the MDS. She said the corporate MDS nurse also reviewed the MDS, and she was not sure how Resident #40's hospice care was missed. She stated by not accurately assessing residents for the MDS it could cause missed information for the resident and expected that all MDS were accurate. Record review of facility policy titled Resident assessment dated 11/2023 indicated, .each facility must follow most updated MDS RAI rules and regulations for completing each MDS accurately and timely . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 2 of 18 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 12/13/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and to establish an accurate reconciliation of controlled drugs in sufficient detail for 1 of 5 residents (Resident #1) and 1 of 5 medication carts (nurse cart for hall 100) reviewed for pharmacy services, in that: The facility failed to verify the amount of lorazepam for Resident #1 in the refrigerated lock box. The facility failed to discard an insulin pen for Resident #39 that had an open date of 11/5/2023. These failures could place residents at risk for misappropriation, drug diversion and the unsafe administrator of medications and not receiving the intended therapeutic benefit of medications. Findings include: 1.Record review of an admission Record dated 12/12/2023 for Resident # 1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of epilepsy (seizure disorder), idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), atherosclerotic heart disease (a buildup of fats and cholesterol that clog the arteries), and Alzheimer's disease (a progressive disease that involves parts of the brain that control thought, memory and language). Record review of a care plan dated 4/25/2022 for Resident #1 indicated he was at risk for injury secondary to seizure disorder with interventions of lorazepam injection prn monitor/document side effects and effectiveness. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 10. No injections of any type were received during the 7 day look back period. Record review of a physician order summary report dated 12/12/2023 for Resident #1 indicated an order for lorazepam solution 2 mg/ml inject 1 mg intramuscularly every 4 hours as needed for seizures dated 9/21/2023. Record review of a narcotic record for Resident #1, undated, indicated amount received from the pharmacy of five vials for Lorazepam 2 mg/ml. Narcotic record sheet did not have any signatures of staff administering medications to Resident #1. During an observation and interview on 12/11/2023 at 3:03 PM, LVN A was assigned the nurse medication cart for hall 100. A narcotic count was conducted with LVN A and during the count, LVN A indicated that Resident #1 had five vials of lorazepam in the lock box in the refrigerator in the medication room. The narcotic sheet indicated that Resident #1 had five vials, and none had been given. LVN A obtained the lorazepam for Resident #1 from the refrigerator in the medication room and the plastic bag had five vials of lorazepam present. Three vials had the tops still on them, two had tops inside of the plastic bag at the bottom. One vial appeared to be a full and the other was partially full. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 3 of 18 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 12/13/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN A said she would notify the DON and the DON came into the medication room and said she would contact the Pharmacy Consultant. LVN A said she was not aware that the vials were not accurate and did not notice the tops were not on the two vials. Interview on 12/11/2023 at 3:08 PM, with the DON who said she had the Pharmacy Consultant on the phone who said that the lorazepam vial top could have come off and the contents spilled inside of the bag. The DON said she could not explain how or why the nurse staff did not recognize the vial was not full or that the tops were off of the vials. Interview on 12/12/2023 at 8:14 AM, with LVN B she said she had been employed at the facility for 4 months and worked days on the 6am-2pm shift. She said before the nurses accept the cart, they count the narcotics with the off going nurse and verify the counts were correct. She said it depended on if the narcotic count was correct, if it was not then they were to contact the DON. She said there was a lock box in the refrigerator in the medication room and they had to go in and count the medications that were there as well. She said she was assigned to work with Resident #1 yesterday morning 12/11/2023. She said she counted with the nurse on 10pm-6am and physically counted the medications. She said they just picked up the bag and saw that there were five vials inside and placed them back. She said that it could be detrimental if they did not verify the counts were accurate or a medication diversion could occur. Interview on 12/12/2023 at 8:21 AM, the DON said she had been employed at the facility since April 2023. She said the nurse that was coming on shift and the nurse that was going off, should be counting, and verifying at the beginning of the shift, if any discrepancies, they should contact her immediately. She said she would then notify the pharmacy, physician and trace down the drug diversion or if an education moment I would be needed if only a signature was missing. She said the pharmacist visited the facility monthly and performed audits of the carts and the medication room. She said residents could be at risk of missing medications, staff could be taking meds, and residents could be missing out on medications. She said she started an in-service yesterday 12/11/2023 on verifying counts and accuracy in vials. Interview on 12/12/2023 at 11:15 AM, LVN C said she had been employed at the facility for 5 years on the 6am-2pm shift. She said with the oncoming nurse they verify the narcotic counts and check the amounts of both and would go into the medication room to verify if the medication had to be refrigerated. She said if any counts were off, they would notify the DON immediately and the DON would back track and trace if someone forgot to sign out for the medication or not. She said the nurse must verify the correct amount that was in the vials. She said staff could be reprimanded if counts were off and not reconciled. She said they had an in-service on yesterday 12/11/2023 to count and verify narcotics. 2. Record review of an admission Record dated 12/12/2023 for Resident #39 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of vascular dementia (a problem caused by brain damage from impaired blood flow to the brain), bipolar disorder (a mental illness that causes shifts in mood), type 2 diabetes (the body either doesn't produce enough insulin or it resists insulin) and myasthenia gravis (causes muscles under your voluntary control to feel weak and get tired quickly). Record review of a physician order summary report dated 12/12/2023 for Resident #39 indicated he did not have an order for an insulin Basaglar Kwik pen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 4 of 18 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 12/13/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Record review of a Quarterly MDS dated [DATE] for Resident #39 indicated he did not have any impairment in thinking with a BIMS score of 15. No injections were given during the last 7 days of the look back period. Record review of a care plan dated 4/1/2021 for Resident #39 had diabetes and was at risk for complications with interventions to educate regarding medications and importance of compliance. Residents Affected - Few During an observation on 12/11/2023 at 2:33 PM of the nurse cart for hall 200, LVN A was present. Resident #39 had an insulin Basaglar Kwik pen with an open date of 11/5/2023. LVN A said the pen should have been discarded within 28 days of the open date. She said Resident #39 had been refusing to take the insulin and did not know why it had not been discarded. She said the medication carts should be checked daily for medications that needed to be discarded or that were expired. Interview on 12/12/2023 at 8:21 AM, with the DON said she had been employed at the facility since April 2023. She said the nurse that was coming on shift and the nurse that was going off were responsible for counting and verifying the cart at the beginning of the shift, if any discrepancies, the DON should be contacted immediately. She said insulin should be discarded within 28 days of the open date. She said she started an in-service with nursing staff on yesterday 12/11/2023 that included insulin dates and expirations. She said Resident #39 had been refusing to take his insulin and did not know why the insulin was still on the medication cart. Interview on 12/12/2023 at 11:33 AM, with the Pharmacy Consultant said she visited the facility monthly and conducted cart audits, medication room checks, medication pass and drug destruction. She said her last visit at the facility was on 12/4/2023 and did not have any concerns at that time. She said insulin should be discarded within 28 days from the open date and if a resident was refusing, then the physician should be notified to discontinue the medication. She said going forward the DON or ADON would do weekly checks on medications for accuracy and medication carts. She said residents could be at risk for their blood sugar not being controlled, giving a false reading of blood sugars, or the potency of the medication could not be good anymore. Interview on 12/12/2023 at 11:33 AM, with the Pharmacy Consultant said she visited the facility monthly and conducted cart audits, medication room checks, medication pass and drug destruction. She said she was contacted by the DON on yesterday 12/11/2023 about some lorazepam vials that were not signed off on the narcotic sheet for Resident #1 and (2) of the five vial tops were off. She said when she visited the facilities, she did not go into the lock boxes in the refrigerators, and it was generally no need to check off and verify if there had not been any doses given. She said every shift the nurses should be checking for accuracy, verifying the count, and checking for any missing volume of liquid medications. She said Resident #1's lorazepam was used for an emergency seizure disorder. She said her last visit at the facility was on 12/4/2023 and she did not have any concerns at that time. She said going forward the DON or ADON would do weekly checks on medications for accuracy and medication carts. She said insulin should be discarded within 28 days from the open date and if a resident was refusing, then the physician should be notified to discontinue the reading of blood sugars, or the potence of the medication could not be good anymore. Interview on 12/13/2023 at 9:40 AM, with the Administrator said she had been employed at the facility since September 18, 2023. She said the medication aides, ADON's, Nurses and Pharmacy Consultant were responsible for checking the medication carts and fridges. She said she was made aware of the discrepancy with the lorazepam vials. She said going forward the nurses would be checking the refrigerator lock box daily and would sign a sheet daily to ensure the lock box had been checked. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 5 of 18 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 12/13/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the medication carts would be checked every shift. She said residents could be at risk for reactions to receiving expired medications. Record review of an in-service training report dated 12/11/2023 conducted by the DON indicated a training on verifying count and correct amount in vial along with insulin dates and discontinue expiration was conducted. Record review of a facility policy titled Storage of Medications with a revision date of 8/2020 read in part, . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of the supplier. 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacture recommends another date or regulations/guidelines require different dating. b. If a vial or container is found without stated date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly, unless otherwise indicated in a facility specific policy. 8. All expired medication will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 6 of 18 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 12/13/2023 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 2 of 6 resident's (Resident #16 and 18) personal refrigerators reviewed for food safety Residents Affected - Few -The facility failed to ensure the refrigerator for Resident #16 did not contain a cup of peach cobbler with mold present. -The facility failed to ensure the refrigerator for Resident #18 did not contain jello, vanilla pudding and salad dressing that were expired. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a facility policy titled Food from Outside Sources with a revised date of 3/2021 read in part, . Residents may have outside sources of food brought in. The community will ensure that proper steps are taken so that the food remains safe. 2. Community personnel will be responsible for the managing of appropriate temperatures and food stored in resident refrigerator . Resident #16 Record review of an admission Record dated 12/12/2023 for Resident #16 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic congestive heart failure (the heart's inability to pump effectively), chronic kidney disease stage 3 (mild to moderate kidney damage), obesity and diabetes mellitus (too much sugar in the blood). Record review of a Quarterly MDS assessment dated [DATE] for Resident #16 indicated she had mild impairment in thinking with a BIMS score of 12. She required set up assistance with eating. During an observation and interview on 12/11/2023 at 10:15 AM, Resident #16's personal refrigerator had a cup of peach cobbler with clear, plastic wrap that had mold on top of the crust. Resident #6 said she ate foods that were in her refrigerator and staff checked it daily. Interview on 12/11/2023 at 3:09 PM, with RA, she said she had been employed at the facility for 2 years and started in the position of RA about 2 months ago. She said she was responsible for checking the personal refrigerators for expired foods. She said she checked the refrigerators daily except for the weekends when she did not work. She said sometimes she would forget to check them if she was busy. During an observation and interview on 12/11/2023 at 3:12 PM, RA was in the room of Resident #6. RA observed the refrigerator and said it looked like the cobbler had mold on top of it and placed it in the trash. She said she did not check her refrigerator that morning and residents could get sick if they ate foods that had mold or was eaten past the expiration dates. Resident #18 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 7 of 18 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 12/13/2023 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of an admission Record dated 12/12/2023 for Resident #18 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of bipolar (a mental illness that causes shifts in mood), major depressive disorder (persistent feeling of sadness or loss of interest), atherosclerotic heart disease (buildup of fats and cholesterol that clogs the arteries) and GERD (acid reflux). Record review of an Annual MDS assessment dated [DATE] for Resident #18 indicated she did not have any impairment in thinking with a BIMS score of 15. She was independent in eating. During an observation and interview on 12/11/2023 at 10:42 AM, Resident #18 was present and said she ate foods out of her personal refrigerator. Her personal refrigerator had multiple four packs of jello that expired May 31, 2023, September 21, 2203, and October 15, 2023. It also had three packs of vanilla pudding that expired May 15, 2023, May 31, 2023, and June 23, 2023. It had a bottle of salad dressing dated January 5, 2023. She said staff checked the refrigerators daily. During an observation and interview on 12/11/2023 at 3:18 PM, RA observed the refrigerator of Resident #18 and multiple items that included jello and pudding were removed and placed in the trash. She said the items were expired. She said residents could get sick if they ate foods that were eaten past the expiration dates. Interview on 9/13/2023 at 9:40 AM, with the Administrator, she said she had been employed at the facility since September 18, 2023. She said the department heads and families were supposed to check the personal refrigerators and no one person was assigned to check them. She said going forward the department heads would be responsible for checking the personal refrigerators daily along with the RA. She said residents could get sick if they ate items out of their refrigerators that were past the expiration dates or if mold was present. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 8 of 18 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 12/13/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (Fiscal year 2023 for the third quarter April 01, 2023 to June 30, 2023) reviewed for administration. -The facility failed to submit accurate registered nurse hours for the following dates: 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023. This failure could place residents at risk for personal needs not being identified and met. Findings include: Record review of PBJ reporting for Quarter 3 (April 01, 2023 to June 30, 2023) indicated no RN hours for 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023. Record Review of timecard editor for 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023 revealed an RN was onsite for at least 8 consecutive hours on those days. The facility did not report those RN hours to PBJ for quarter 3 reporting cycle. During an interview on 12/11/2023 at 2:15 pm, the staffing coordinator stated that she was responsible for scheduling the nurses and aides. She stated there was an RN present on those days and provided timecard for RN D revealing RN D had worked on those days for 8 consecutive hours. During an interview on 12/11/2023 at 3:00 pm, the administrator stated she had started in September 2023 and the PBJ report and hours were completed at the corporate level. She stated she was not sure why there were no RN hours reported for those days. During an interview on 12/12/2023 at 9:44 am, the VP of program management stated the staffing hours were pulled from the clock in and out system. She stated there had been an issue with the system and was not aware and those RN hours could have gotten missed during that time. She stated the facility was to monitor hours onsite and she only submitted the hours that were in the system. She stated there was no system to check that the staffing hours were accurate and submitted what information was on the time spreadsheet. During an interview on 12/12/2023 at 2:22 pm, the administrator stated she was not aware that accurate RN hours were not being submitted to the PBJ. She stated she reviewed the RN hours for the missing days and there was an RN present. She stated that the RN working was a shared employee, and a report had to be sent to corporate payroll for shared hour employees. She stated those hours must have gotten missed. She stated she did not see any risk to inaccurate reporting of RN hours but would review the hours more closely before submitting to the corporate payroll. Record review of policy manual for Electronic Staffing Data Submission Payroll-Based Journal dated June 2022 indicated, .accuracy: staffing information is required to be accurate and complete submission of a facility's staffing records. Hours: facility must submit the number of hours each staff member is paid to deliver services for each day worked . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 9 of 18 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 12/13/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 16 (room [ROOM NUMBER] and room [ROOM NUMBER]) rooms reviewed for pest control. Residents Affected - Few -The facility failed to ensure room [ROOM NUMBER] and room [ROOM NUMBER] did not contain live roaches. This failure could place residents at risk of a diminished quality of life due to an unsafe environment. Findings include: During an observation on 12/11/23 at 9:57 am, one live roach was observed crawling around the toilet in room [ROOM NUMBER]. During an observation on 12/11/23 at 10:16 am, one live roach was observed crawling under the bed in room [ROOM NUMBER]. During an interview on 12/11/23 at 10:37 am, HSK E stated she had been in housekeeping for 10 years. She stated there had been roaches in the rooms and building on and off and she would kill them, clean the area and report to the administrator and maintenance director. She stated pest control was in the facility about 1-2 weeks ago and sprayed but the families bring in items that have roaches. During an interview on 12/11/23 at 10:40 am, CNA F stated she had worked as needed at the facility for two years. She stated she had not seen any roaches in any rooms, but this was the first time she had worked 200 hall in 4 months. She stated if she were to see any pest like roaches she would report to the administrator and maintenance director. During an attempted interview on 12/11/23 10:45 am, Maintenance director was on leave and unavailable for interview. During an interview on 12/11/23 at 11:47 am, the administrator stated she was aware of the roaches on 200 hall and pest control had been treating the rooms. She stated pest control comes monthly and did an emergent visit a few weeks ago for roaches in room [ROOM NUMBER]. She stated families bring in items and the facility frequently monitored and notified pest control of any issues. She stated the facility had not put in place a food storage system for resident rooms. She stated she thought the roaches were gone on 200 hall and would contact pest control again. During an interview on 12/12/23 at 11:09 am, the pest control service manager stated they had been servicing the facility monthly and as needed for active pest. He stated the facility had an oncoming issue with roaches, but they had been treating them and controlling the situation. He stated German roaches were brought in by visitors and were difficult to eradicate. He stated they were now inspecting all rooms monthly for signs of pest and treating rooms as needed. He stated the technician treated the rooms on 200 hall on 11/28/2023 and again 12/12/2023. He stated the pest control plan was appropriate and the facility did not require a change at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 10 of 18 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 12/13/2023 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 0925 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/13/2023 at 10:10 am, the administrator stated pest control came again 12/12/2023 and sprayed rooms [ROOM NUMBERS]. She stated the residents in those rooms had been relocated until after the rooms were treated. She stated by not having an effective pest control program it could lead to infection from pest. She stated she would implement a new program for food storage in the rooms and expected for the facility to be pest free. Residents Affected - Few Record review of monthly pest control service report from 05/01/2023 to 11/01/2023 revealed the facility had roaches and required regular treatment. The roaches were reported in the kitchen and on 200 hall during those times. On 11/28/2023 an emergent visit was made for live roaches in room [ROOM NUMBER]. Record Review of policy titled Pest Control dated May 2008 indicated, .this facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 11 of 18 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 12/13/2023 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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 2 of 15 employees (LVN H and CNA K) new and existing staff reviewed for training. Residents Affected - Few -The facility failed to ensure LVN H was trained on HIV, fall prevention, dementia, and restraint reduction annually and completed 2-hour quarterly trainings annually. -The facility failed to ensure CNA K was trained annually for restraint reduction. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings include: Record review of LVN H personnel file indicated LVN H was hired on 08/02/2022 and had not completed annual training on HIV, fall prevention, dementia care, restraint reduction and completed two hours of quarterly training. Record review of CNA K's personnel filed revealed CNA K was hired on 8/08/2017 and had not completed annual training on restraint reduction. Interview on 12/13/2023 at 2:15 pm, with the DON, she said she had been employed as the DON since April 2023. She said she and the ADON were responsible for overseeing the on hire and annual trainings and was not aware LVN H had not completed her annual trainings on HIV, fall prevention, dementia care, restraint reduction and required 2-hour quarterly trainings and CNA K had not completed training annually for restraint reduction. She said there was no monitoring system to ensure trainings were completed and each employee was aware of their required trainings in the online system. She said if staff are not properly trained it could affect resident care. Interview on 12/13/2023 at 2:49 pm, with the Administrator, she said she was ultimately responsible for oversight all trainings. She said trainings were assigned in the online training system and each employee was responsible for completing the required trainings. She said staff that were not trained could affect resident care and expected all staff to complete required regulated trainings annually and on hire. She said the facility did not have a policy on staff development or training education. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 12 of 18 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 12/13/2023 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 0941 Level of Harm - Minimal harm or potential for actual harm Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on interview and record review, the facility failed to provide effective communications mandatory training for 2 of 15 employees (LVN H and CNA J) reviewed for training, in that: Residents Affected - Few -The facility failed to ensure effective communication training was provided to LVN H annually. -The facility failed to ensure effective communication training was provided to CNA J on hire. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. Findings include: Record review of LVN H's personnel file revealed LVN H was hired on 08/02/2022 and had not completed annual training on effective communication. Record review of CNA J's personnel filed revealed CNA J was hired on 8/29/2023 and had not completed on hire training on effective communication. Interview on 12/13/2023 at 2:15 pm, with the DON, she said she had been employed as the DON since April 2023. She said she and the ADON were responsible for overseeing the on hire and annual trainings and was not aware LVN H had not completed her annual trainings effective communication and CNA J had not completed training on hire for effective communication. She said there was no monitoring system to ensure trainings were completed and each employee was aware of their required trainings in the online system. She said if staff are not properly trained it could affect resident care. Interview on 12/13/2023 at 2:49 pm, with the Administrator, she said she was ultimately responsible for oversight all trainings. She said trainings were assigned in the online training system and each employee was responsible for completing the required trainings. She said staff that were not trained could affect resident care and expected all staff to complete required regulated trainings annually and on hire. She said the facility did not have a policy on staff development or training education. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 13 of 18 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 12/13/2023 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 0942 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 1 of 15 employees (LVN H) reviewed for training, in that: -The facility failed to ensure required education was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted by LVN H annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of LVN H's personnel file revealed LVN H was hired on 08/02/2022 and had not completed annual training on rights of the resident and responsibilities of a facility to properly care for its residents. Interview on 12/13/2023 at 2:15 pm, with the DON, she said she had been employed as the DON since April 2023. She said she and the ADON were responsible for overseeing the on hire and annual trainings and was not aware LVN H had not completed her annual training on rights of the resident. She said there was no monitoring system to ensure trainings were completed and each employee was aware of their required trainings in the online system. She said if staff are not properly trained it could affect resident care. Interview on 12/13/2023 at 2:49 pm, with the Administrator, she said she was ultimately responsible for oversight all trainings. She said trainings were assigned in the online training system and each employee was responsible for completing the required trainings. She said staff that were not trained could affect resident care and expected all staff to complete required regulated trainings annually and on hire. She said the facility did not have a policy on staff development or training education. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 14 of 18 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 12/13/2023 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to provide the required annual or new hire Abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention for 1 of 15 employees (LVN H) reviewed for training. -The facility failed to ensure abuse training including activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, Dementia management and resident abuse prevention was provided to the LVN H annually. This failure could affect residents and place them at risk abuse due to lack of staff training. Findings include: Record review of LVN H's personnel file revealed LVN H was hired on 08/02/2022 and had not completed annual training on abuse. Interview on 12/13/2023 at 2:15 pm, with the DON, she said she had been employed as the DON since April 2023. She stated she and the ADON were responsible for overseeing the on hire and annual trainings and was not aware LVN H had not completed her annual trainings on abuse. She stated there was no monitoring system to ensure trainings were completed and each employee was aware of their required trainings in the online system. She stated if staff are not properly trained it could affect resident care. Interview on 12/13/2023 at 2:49 pm, with the Administrator, she said she was ultimately responsible for oversight all trainings. She said trainings were assigned in the online training system and each employee was responsible for completing the required trainings. She said staff that were not trained could affect resident care and expected all staff to complete required regulated trainings annually and on hire. She said the facility did not have a policy on staff development or training education. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 15 of 18 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 12/13/2023 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 7 of 15 employees (LVN G, LVN H, CNA J, CNA K, CNA L, FSS, and Rehab Director) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to LVN G, LVN H, CNA J, CNA K, CNA L, FSS, and Rehab Director. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings: Record review of LVN G's personnel file revealed LVN G was hired on 9/19/2023 and had not completed on hire QAPI training. Record review of LVN H's personnel file revealed LVN H was hired on 08/02/2022 and had not completed annual training on QAPI. Record review of CNA J's personnel filed revealed CNA J was hired on 8/29/2023 and had not completed on hire QAPI training. Record review of CNA K's personnel file revealed CNA K was hired on 8/08/2017 and had not completed annual training on QAPI. Record review of CNA L's personnel file revealed CNA L was hired on 9/12/2023 and had not completed on hire QAPI training. Record review of FSS's personnel file revealed the FSS was hired on 11/28/2023 and had not completed on hire QAPI training. Record review of the rehab director's personnel file revealed the rehab director was hired on 10/26/2020 and not completed annual training on QAPI. During an interview on 12/13/2023 at 2:15 pm, the DON stated she had been employed as the DON since April 2023. She stated she and the ADON were responsible for overseeing the on hire and annual trainings and was not aware of the required QAPI training for all employees. She stated there was no monitoring system to ensure trainings were completed and each employee was aware of their required trainings in the online system. She stated if staff are not properly trained it could affect resident care. During an interview on 12/13/2023 at 2:49 pm, the administrator stated she was ultimately responsible for oversight all trainings. She stated trainings were assigned in the online training system and each employee was responsible for completing the required trainings. She stated she was not aware that all employees required QAPI training but would see that the training was assigned to every employee. She stated staff that were not trained could affect resident care and expected all staff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 16 of 18 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 12/13/2023 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 0944 Level of Harm - Minimal harm or potential for actual harm complete required regulated trainings annually and on hire. She stated the facility did not have a policy on staff development or training education. . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 17 of 18 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 12/13/2023 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 0949 Level of Harm - Minimal harm or potential for actual harm Provide behavior health training consistent with the requirements and as determined by a facility assessment. Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 1 of 15 employees (FSS) reviewed for training, in that: Residents Affected - Few The facility failed to ensure effective behavioral health training was provided to the FSS on hire. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings: Record review of FSS's personnel file revealed the FSS was hired on 11/28/2023 and had not completed on hire behavioral health training. During an interview on 12/13/2023 at 2:15 pm, the DON stated she had been employed as the DON since April 2023. She stated she and the ADON were responsible for overseeing the on hire and annual trainings for nursing staff and non-nursing staff were the responsibility of the administrator. She stated there was no monitoring system to ensure trainings were completed and each employee was aware of their required trainings in the online system. She stated if staff are not properly trained it could affect resident care. During an interview on 12/13/2023 at 2:49 pm, the administrator stated she was ultimately responsible for oversight all trainings. She stated trainings were assigned in the online training system and each employee was responsible for completing the required trainings. She stated she was not aware the FSS had not completed behavioral health training on hire. She stated staff that were not trained could affect resident care and expected all staff to complete required regulated trainings annually and on hire. She stated the facility did not have a policy on staff development or training education. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 18 of 18