Inspection·March 6, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed a form 1012 completed. She said the form 1012 was completed if a resident developed a diagnosis from (psych company) that they did not have on admission. She said there was no risk to the resident for not completing a new PASRR level 1. She said the purpose of the screening was to identify positive residents to see if they could receive certain services. In an interview on 3/6/25 at 4:12 p.m., the Administrator said she informed the CRC nurse to check any resident who could possibly require a 1012 back in December 2024. She said the CRC nurse should review the diagnoses on admission and during the care plan review. She said there was nothing to alert the staff on a repeat PASRR screening, but she educated them on reviewing diagnoses. Record review of the facility's PASRR policy, revised 11/15/23, read in part, .the purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately . 2. PL1s are put into Simple LTC by the facility CRC within 72 hours of resident admitting to facility .6. Follow Texas PASRR policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status. 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 03/06/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #14) reviewed for respiratory care. Residents Affected - Few The facility failed to ensure Resident #14's oxygen was not administered at 5 liters per minute on 3/4/25 and 3/6/25 instead of 2-4 liters per minute as ordered by the physician. This failure could place residents at risk of not receiving medications and treatments as ordered by the physician. The findings include: 1. Record review of Resident #14's admission record, dated 3/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included cerebral infarction (stroke), dementia (a decline in cognitive functions such as memory, reasoning, and communication, significantly affecting daily life), congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and atrial fibrillation (an irregular and often very rapid heart rhythm). Record review of Resident #14's quarterly MDS assessment, dated 2/4/25, revealed a BIMS score of 13 out of 15, which indicated her cognition was intact. She required assistance from staff with ADL care and was on oxygen therapy. Record review of Resident #14's, undated, care plan revealed she was on oxygen therapy related to respiratory illness; date initiated 8/23/21. Interventions were to give medications as ordered by the physician and oxygen settings: O2 2 liters/minute per nasal cannula, date initiated 8/23/21. Record review of Resident #14's Physician orders, dated 3/6/25, revealed an order for O2 at 2-4 L/min via nasal cannula PRN to maintain O2 sats > 90% as needed. Document each shift that oxygen was used, the resident's O2 sat, and notify MD for changes in condition, order date 9/13/24. Record review of Resident #14's Nursing note dated 1/22/25 written by RN P read in part, Upon entering in the room resident stated that I have breathing difficulty Resident head is already in up position and on O2 5L via NC. PRN breathing tx given. Vitals at this time . SPO2 - 97% on 5L O2 via NC. No RS destress [sic] noted. Resident is alert and oriented x 4. Notified to [sic] NP (name) is here in facility. Record review of Resident #14's Medication Administration Record for March 2025 revealed no documentation of O2 given or O2 saturations. Record review of Resident #14's, undated, O2 Sats Summary revealed the last recorded O2 saturation on the summary sheet was 96% on 12/28/24. In an observation on 3/4/25 at 10:17 a.m. revealed Resident #14 was lying in bed with her nasal (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 03/06/2025 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 0695 cannula in place. The oxygen was on 5 L. Level of Harm - Minimal harm or potential for actual harm In an observation on 3/6/25 at 11:08 a.m. revealed Resident #14 was lying in bed with her nasal cannula in place and oxygen running at 5 L. The resident said her oxygen was ok. Residents Affected - Few In an interview on 3/6/25 at 11:12 a.m., LVN M said Resident #14's oxygen should be between 2-4 L. She said she had not checked the rate this morning yet. In an interview on 3/6/25 at 11:49 a.m., LVN M said Resident #14's oxygen was running at 5 L but was on 4 L when she checked it yesterday morning, 3/5/25. She said there was a risk of having to titrate her down off the oxygen. In an interview on 3/6/25 at 11:56 a.m., Resident #14 said she sometimes had to have the oxygen rate turned up because she wheezed a lot. She said she would notify the nurse that she could not breathe well and LVN M or another nurse (unknown) would come in and fix it. She said she sometimes had to have the oxygen turned up to 6 or 7 liters per minute. She said the oxygen was ok now. In an interview on 3/6/25 at 3:24 p.m., the DON said if the rate was not on the correct level staff would not be following MD orders. She said there was no risk to the patient for being on more oxygen. In an interview on 3/6/25 at 4:12 p.m., the Administrator said she expected staff to follow MD orders and to document any changes. Record review of the facility's oxygen therapy policy, dated 4/2021, read in part, .it is the policy of this community to ensure all oxygen administration is conducted in a safe manner . Procedure: 1. Verify there is an order for oxygen administration to include: a. method of delivery b. flow rate, c. oxygen saturation parameters if indicated .3. Assess resident's respiratory status . 6. Start oxygen flow of rate as ordered. 7. Document resident's response to prn oxygen therapy: a. date and time of oxygen administration b. type of delivery c. oxygen rate d. assessment of resident's respiratory status to include oxygen saturation via pulse oximetry (a quick, noninvasive test that measures the oxygen saturation levels in the blood) 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 03/06/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 28% based on 7 errors out of 25 opportunities which involved 3 of 8 residents (Residents #20, #44 and #16) and 2 of 5 staff (MA A and RN M) reviewed for medication administration. Residents Affected - Some 1. The facility failed to ensure MA A did not crush and administer Potassium CL micro 10 mEQ ER (an extended-release medication, that should not be crushed, used to prevent or to treat low blood levels of potassium) and failed to ensure MA A administered the full dose of Clearlax 3350 (used to treat occasional constipation) to Resident #20 on 3/5/25. 2. The facility failed to ensure MA A did not administer Ciprofloxacin 3% eye drops (antibiotic eye drop) and Dexamethasone 0.1 % eye drops (a steroid medicine used to treat eye inflammation) to Resident #44 on 3/5/25, without a Physicians order. 3. The facility failed to ensure MA A provided sufficient time for absorption between eye medications when she administered Bromfenac 0.09% along with other eye medications to Resident #44 on 3/5/25. 4. The facility failed to ensure MA A did not administer Refresh tears eye drops (lubricates and moisturizes the eyes) instead of Lacri-lube ointment (used to relieve dry, irritated eyes) to Resident #44 on 3/5/25 according to Physician orders. 5. The facility failed to ensure RN M set Resident #16's IV Vancomycin (an antibiotic used to treat or prevent bacterial infections that are resistant to other drugs) to the correct flow rate according to the pharmacy label on 3/6/25. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects and decline in health. Findings include: 1. Record review of Resident #20's face sheet, dated 3/6/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included dementia (a decline in cognitive functions such as memory, reasoning, and communication, significantly affecting daily life), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and spondylosis (age-related condition where the joints and cartilage lined discs of the neck are affected). Record review of Resident #20's quarterly MDS assessment, dated 2/18/25, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #20's Physician orders for March 2025 revealed orders for: Potassium chloride Crys ER 10 mEQ give 1 tablet by mouth one time a day for hypokalemia (low potassium) give with 8 oz of water. Do not crush and may dissolve in water, order date 10/8/24, (continued on next page) 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 03/06/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Miralax oral powder 17 gm/scoop give 1 scoop by mouth one time a day for constipation, order date 7/11/24. May alter medications by crushing, opening capsules or administration in food or fluid (only open or crush medications if manufacture allows), order date 7/11/24. Residents Affected - Some In an observation on 3/5/25 at 9:14 a.m. revealed MA A prepared Resident #20's medication for administration. She prepared 11 pills which included Potassium CL micro 10 mEQ ER. The pharmacy label on the Potassium read do not crush, may dissolve in water. MA A crushed the Potassium ER along with the other medications and administered it to Resident #20. MA A prepared Resident #20's Clearlax 3350. Observation of the inside of the Clearlax measuring top revealed there was the number 17 and an up arrow that pointed to the top of a white area. MA A poured Clearlax powder into the top but stopped below the 17-gram line. She mixed the powder with water and administered it to Resident #20. In an interview on 3/5/25 at 10:20 a.m., MA A said she crushed the potassium along with the other medications but should have put Potassium in the water and allowed it to dissolve. She said she crushed it instead of allowing it to dissolve in water because Resident #20 said sometimes the medication was too gritty. She said she administered approximately 15 - 16 grams of the Clearlax because the powder was underneath the 17-gram line. She said she was supposed to cover up the 17-gm line and she normally had a measuring cup. She said the resident did not receive the full dosage and there was a risk of him not having a bowel movement. She said she was trained to pay attention and limit distractions. In an interview on 3/6/25 at 2:57 p.m., the DON said the pharmacy label should be reviewed while preparing medications. She said the MA could not crush Potassium ER but was unsure why. She said Miralax (another name for Clearlax) was for constipation and staff should pour the powder to the dosage line. She said if the resident did not get the full amount, it could cause them not to have a bowel movement. 2. Record review of Resident #44's face sheet, dated 3/5/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), age-related cataract, right eye (a condition affecting the eye that causes clouding of the lens), optic atrophy, left eye (damage to your optic nerve), myopia, left eye (a condition in which one can see near objects but cannot see far objects clearly), and presence of intraocular lens (clear, artificial lenses that replace your eye's natural ones). Record review of Resident #44's quarterly MDS assessment, dated 2/26/25, revealed a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. He was independent with eating, oral hygiene, toileting hygiene, and personal hygiene and required assistance from staff with showers and dressing. Record review of Resident #44's Physician orders for March 2025 revealed orders for: Dexamethasone ophthalmic solution 0.1% instill 1 drop in right eye drop one time a day for eye surgery for 1 week, order date 2/6/25, Refresh Lacri-Lube ointment (artificial tear ointment) instill 1 strip in both eyes three times a day for dry eyes, order date 6/20/23, (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 03/06/2025 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 0759 There were no active orders for Ciprofloxacin 3% and Bromfenac 0.09%. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #44's Order Audit Report, dated 3/5/25, revealed Bromfenac 0.09% had an end date of 3/4/25. Residents Affected - Some Record review of Resident #44's Order Audit Report, dated 3/6/25, revealed Ciprofloxacin 0.3% had an end date of 2/25/25. In an observation on 3/5/25 at 9:35 a.m., MA A prepared 4 eye medications for Resident #44 which included Refresh tears eye drops, Dexamethasone 0.1% eye drops, Bromfenac 0.09% eye drops, and Ciprofloxacin 3% eye drops. At 9:43 a.m., she administered two drops of Refresh tears to both of Resident #44's eyes, at 9:45 a.m. she administered one drop of Dexamethasone 0.1% to his right eye, at 9:46 a.m. she administered one drop of Bromfenac 0.09% to his right eye, and at 9:47 a.m. she administered one drop of Ciprofloxacin 3% to his right eye. The Bromfenac 0.09%, Ciprofloxacin 3%, and Dexamethasone 0.1% pharmacy label read wait at least 5 min between eye meds. In an interview on 3/5/25 at 10:05 a.m., MA A said she administered a total of 4 eye medications to Resident #44. She said she administered 2 drops of Refresh tears to each of Resident #44's eyes because he used to take two in both eyes. MA A said the MAR provided instructions. She reviewed the MAR and noted the order was for Lacri-lube ointment instead of the eye drops. She said she did not realize the order was for the ointment and thought he was prescribed 2 drops. She said she reviewed the MAR and thought the other eye medications were also on there, but said he completed them yesterday and it was a medication error. She said discontinued medications should be removed from the cart and put in the discontinued bin in the medication room to prevent errors. She said she gave the wrong medication and did not check for the correct patient, direction, time, and dose. She said it could affect his eyes. She said she should wait 2-3 minutes between eye medications to ensure the medication did not wash out or interfere with one another. She looked at the pharmacy label and said it instructed to wait 5 minutes between eye medications. In an interview on 3/6/25 at 2:57 p.m., the DON said the Medication aide should verify the correct resident, review the eMAR, and compare the eMAR to the medication. She said the MA should wait approximately 5 minutes between eye medications because of the absorption rate and drug interactions. She said discontinued medication should be removed from the cart and put in the discontinued pile. She said if the medication was not on the eMAR, there was no order. She said going past the duration time set forth by the MD could cause the resident to take too much antibiotic. 3. Record review of Resident #16's face sheet, dated 3/6/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included spontaneous bacterial peritonitis (an infection of the peritoneum, the thin membrane lining the inner abdominal wall), pancytopenia (all of the types of blood cells are low), and human immunodeficiency virus (a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases). Record review of Resident #16's admission MDS assessment, dated 2/10/25, revealed a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. The MDS revealed he had central IV access and received IV antibiotics. Record review of Resident #16's Physician Orders for February 2025 revealed the following orders: (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 03/06/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Vancomycin intravenous 750 mg/150 ml use 750 mg intravenously every 12 hours for infection, order date 3/4/25. In an observation and interview on 3/6/25 at 9:20 a.m., RN M flushed Resident #16's PICC lumens and hung the Vancomycin. She selected Vancomycin 750 mg/150 mL premix in the machine, and it set the rate to 120 mL/hr. Observation of the vancomycin bag and pharmacy label revealed it was Vancomycin 750 mg/250 mL. The pharmacy label read, Activate and mix immediately prior to use vancomycin 750 mg in 250 mL 0.9% sodium chloride infuse intravenously at 166 mL/hr over 90 minutes: every 12 hours . This State Surveyor inquired about the rate and RN M said the machine had presets and she selected the closest premix and would ask the DON to have the machine calibrated. RN M reset the machine and updated the rate to 166 mL/hr to reflect the pharmacy label. She said she previously did not know she could adjust the rate on the machine. She said Vancomycin was a rough medication and the medication would run for a longer time now but was set to match the pharmacy label. In an interview on 3/6/25 at 2:57 p.m., the DON said the Consultant Pharmacist previously made rounds with the medication aide and nurse and conducted skills checks. She said she expected nursing staff to verify the right medication, patient, route, time, dose, and pain level. She said the pharmacy provided the IV rate. She said the rate was located on the packing and the machine and if the two did not match, staff should follow the rate on the packaging. She said the Vancomycin rate was important because of the therapeutic level. She said staff should ensure it did not infuse too fast or too slow. In an interview on 3/6/25 at 4:12 p.m., the Administrator said she expected nursing staff to follow the guidelines per facility policy and to review the MARs prior to medication administration. She said staff should verify the right dosage and ensure the MAR matched. Record review of the facility's Administration Procedures for All Medications, revised 8/2020, read in part, .Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications . Procedures . III. 5 Rights (at a minimum) at a minimum, review the 5 rights at each of the following steps of medication administration. 1. Prior to removing the medication package/container from the cart/drawer: a. check the MAR/TAR for the order . c. if unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information . 2. Prior to removing the medication from the container: a. Check the label against the order on the MAR. b. Note any supplemental labeling that applies 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 03/06/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 (medication room refrigerator) of 1 medication refrigerators reviewed for pharmacy storage. The facility failed to maintain the medication refrigerator in the medication room between 36-46 degrees Fahrenheit per facility policy. This failure could place residents at risk of not receiving the desired therapeutic effect from their medications. The findings include: Record review of the Med Room Refrigerator Log, dated March (no year), revealed on 3/1 the morning and evening temperature was 20 degrees Fahrenheit. From 3/2 - 3/4 the morning and evening temperature was 31 degrees Fahrenheit. From 3/5 - 3/6 the morning and evening temperature was 30 degrees Fahrenheit. The bottom of the log read, Maintain refrigerator temperature within the following range: 36 - 46 F. Temperatures were documented by MA A from 3/2 - 3/6. In an observation on 3/6/25 at 1:35 p.m. of the white refrigerator in the medication room revealed the thermometer read 30 degrees F. There were multiple medications in there which included: Influenza Vaccine Flucelvax, box read to store between 36 - 46 degrees F; Lantus Solostar insulin pens; 4 boxes of Trulicity injection, box indicated to refrigerate at 36 - 46 degrees F; and Humira, box read to store in refrigerator at 36 - 46 degrees F. No medication appeared frozen. In an interview on 3/6/25 at 2:25 p.m. MA A said any temperature reading less than 30 degrees F indicated the refrigerator was not working per the DON. She said if the thermometer read 21 degrees F it was out. She said she checked the refrigerator in the morning at 6 a.m. and again at 2 p.m. She said the temperature was between 30- and 31-degree F and it may need a new thermometer. She said the DON was aware the thermometer read 30 degrees F and if the medications froze it would be no good. In an interview on 3/6/25 at 3:19 p.m., the DON said the medication refrigerator temperature should be between 38 - 41 degrees F. She said 30 degrees F was below freezing and nothing in the refrigeration was frozen. She said staff should notify her of the temperature readings to either get a new refrigerator and/or thermometer. She said staff informed her about the readings approximately one week ago and she replaced an old thermometer, but staff did not report readings to her again. She said certain temperatures could destroy the medication making them non-effective. She said medications should be stored properly. In an interview on 3/6/25 at 4:12 p.m., the Administrator said staff should check the medication refrigerator daily to ensure medication were stored at the proper temperature. Record review of the facility's Storage of Medications policy, revised 8/2024, read in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing (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 03/06/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . II. Temperature 1. All medications are maintained within the temperature ranges noticed in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC) . c. refrigerated: 36F to 46F with a thermometer to allow temperature monitoring .2. Medications and biologicals are stored at their appropriate temperatures and humidity according to the USP guidelines for temperature ranges .4. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36F and 46F with a thermometer to allow temperature monitoring 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 03/06/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 03/06/2025) reviewed for food and nutrition services. Residents Affected - Few The facility failed to ensure the menu was followed for the lunch meal by leaving out the winter fruit cup, egg roll, or water for all diet types on 03/06/2025. This deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss. Findings include: Observation on 03/06/2025 at 11:52 AM, in the main dining area revealed trays were passed with a total of 18 residents in the dining room with 1 nurse. Upon observation, residents did not receive an egg roll, winter fruit cup, or water. Observation and record review on 03/06/2025 at 12:07 PM of the kitchen, revealed the food was already being put away and there was no food left on the steam tables. At that time, a test tray was requested, and the menu was reviewed. The menu displayed for 03/06/2025, reflected egg roll, mandarin chicken, steamed rice, seas broccoli florets, winter fruit cup, iced tea, and water. The test tray was received in the conference room for the state survey team at 12:23 PM. There were no egg rolls or bread, fruit cup, or water were observed, and there was observation of trays being sent to resident halls, who did not have the substitution of egg roll for bread, fruit cup, or water. Interview on 03/06/2025 at 12:36 PM with the Dietary Manager revealed the egg rolls were not served because there was a substitution for the day, which should have been bread. The Dietary Manager said everyone should have received bread, because there weren't enough egg rolls for all residents. The Dietary Manager also stated at time, the egg rolls were fried, which could make them hard for the residents to chew. The Dietary Manager stated each resident should get water with their meal and tickets were checked for each tray before it was given to a resident. The Dietary Manager stated orders for the following week were placed on Friday and delivered by Tuesday of the next week. If a substitution was made, there was a form completed by the Dietary Manager with why the meal option was being substituted and with what meal item. A record review of the meal substitution from March 1, 2025, to March 6, 2025, revealed there were 5 menu changes, due to not having the menu items that were displayed to residents. The Dietary Manager stated for the winter fruit cup, they did not have any fruit, and it was substituted with donut holes, regardless of special diets. Interview on 03/06/2025 at 4:11 PM, the Administrator stated her expectations of the food, was to be served as it was at a restaurant. The Administrator continued to say she expected the food to be palatable and at the proper temperature for the residents, but she knew sometimes that was not the case. The Administrator stated she checked tickets when she was assisting with serving the residents to ensure they were receiving everything on the ticket. It was to the Administrators understanding the reason why they had food complaints was regarding the menu not being resident focused, as they followed a corporate dietary menu for all residents. The Administrator stated she did the best she could with speaking to the Dietary Manager regarding the menu and how they could make changes to include all diets, while keeping the meal palatable. The Administrator stated they were going to try and add additional flavorful seasoning packets to each tray, as the seasoning did not contain salt. The (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 03/06/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator stated for items that were to be substituted, but not placed on the resident's tray, she was not sure why that was happening. The Administrator stated the Dietary Manager was good at making sure all items were placed on each tray, according to the ticket of each resident. Record review of the facility's menu, dated 03/06/2025, reflected for Thursday (03/06/2025) the following: Lunch-Mandarin Chicken, Steamed Rice, Seas Broccoli Florets, Egg Roll, Winter Fruit Cup, Iced Tea, and Water. 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 03/06/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Resident #16) reviewed for infection control. Residents Affected - Few The facility failed to ensure RN M wore appropriate PPE when administering IV medication to Resident #16 on 3/5/25, who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes). This failure could place residents at risk of infectious diseases due to improper infection control practices. Findings include: Record review of Resident #16's face sheet, dated 3/6/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included spontaneous bacterial peritonitis (an infection of the peritoneum, the thin membrane lining the inner abdominal wall), pancytopenia (all of the types of blood cells are low), and human immunodeficiency virus (a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases). Record review of Resident #16's admission MDS assessment, dated 2/10/25, revealed a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #16 had central IV access and received IV antibiotics. Record review of Resident #16's Physician Orders for March 2025 revealed the following orders: Normal Saline Flush use 10 ml intravenously every shift for infection PICC line - flush with 10 ml normal saline prior to medication administration, order date 2/8/25, Vancomycin intravenous 750 mg/150 ml use 750 mg intravenously every 12 hours for infection, order date 3/4/25. In an observation on 3/6/25 at 9:20 a.m. revealed RN M prepared Resident #16's IV medication for administration. She entered his room, washed her hands, put on gloves but did not put on a gown. There was an orange enhanced barrier precautions sign posted behind his bed that read, STOP . providers and staff must also wear gloves and gown for the following high-contact resident care activities . device care or use: central line There were two individually wrapped gowns on top of the resident's dresser, there were no gowns in a plastic bin near the doorway. RN M flushed his PICC lumen (a smaller tube that splits from a PICC line outside the body) with normal saline and hung his IV Vancomycin. In an interview on 3/6/25 at 9:45 a.m., RN M said Resident #16 was on enhanced barrier precautions and she should gown up. She said she did not gown up because the PPE cart in the resident's room was empty. She said enhanced barrier precautions was used for infection control and there could be a risk of transferring germs from resident to staff and/or staff to resident. She said Resident #16 was on IV Vancomycin for a peritoneal infection. (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 03/06/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 3/6/25 at 2:32 p.m. the DON, who was also the Infection Preventionist, said she educated staff that enhanced barrier precautions were to provide extra protection for the residents and staff. She said staff should wear nonsterile gowns and gloves when providing direct care or if staff would be around the resident more than 5 minutes. She said enhanced barrier precautions were used for residents who had any opening that was not natural such as a central and PICC line, g-tube, foley catheter, and wound. She said the nurse should wear gown and gloves if giving an IV medication. She said the box at the door was an indicator to staff that a resident was on EBP. She said there was a greater risk for transmission of infection if proper PPE was not worn. In an interview on 3/6/25 at 4:12 p.m., the Administrator said she expected staff to follow guidelines and protocol regarding enhanced barrier precautions. She said there were signs up for enhanced barrier precautions and staff should don a gown, gloves, and mask when entering the resident's room. She said they went over EBP for months and staff should know exactly what to do. She said the DCO and ADCO were responsible to ensure EBP protocol was in place. Record review of the facility's Enhanced Barrier Precautions policy, dated 4/1/24, read in part, .Enhanced Barrier Precautions are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings, including nursing homes. EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO, or who have open wound or indwelling medical device . Procedure .2. Determine if any of the following indwelling medical devices are in use: . central lines . EBP will be implemented if any of the above wounds or invasive medical devices are present. 3. Place signage on resident's closet door, maintain PPE in residents' room and assure all team members aware of resident status and need for EBP during high contact care. 4. High contact resident care activities . device care or use: central line FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675849 If continuation sheet Page 14 of 14