Health inspection·February 27, 2026

F 0773 Level of Harm - Actual harm Residents Affected - Few verified? Y). (Note: The lab directly called the doctor and not the facility. Record review of Resident #1's hospital records, dated 02/02/2026, revealed in part: Chief complaint via EMS from facility c/o abdominal pain x 3 days, acid reflux. Pt has been having high glucose readings x1 week reading high. Kussmaul respirations (an abnormal breathing pattern characterized by rapid, deep breathing at a consistent pace. It's a sign of a medical emergency - usually diabetes-related ketoacidosis (DKA), which can affect people with diabetes and people with undiagnosed Type 1 diabetes). [AGE] year-old male, bilateral blindness, chest burning since last three days. He was also complaining of polyuria (Urinating a lot) and poor appetite and glucometer reading as high since last one week. He was never diagnosed with diabetes in the past. Blood work showed glucose 743. Diabetic [NAME] Acidosis (a serious health condition that could happen as a result of diabetes. It could be life-threatening). Assessment/Plan of Lactic Acidosis, Diabetic Ketoacidosis, and newly diagnosed diabetes mellitus on 02/02/26. Plan - s/p 2 L NS in ER, Will give 2 more liters of LR fluid boluses start DKA protocol insulin and IV fluids. NPO for now ok meds and ice chips. Routine chemistry: Glucose levels 2/3/26 = 195, 2/4/2026 = 297, 2/5/2026 = 155. Start statin once tolerating diet transfer to PCU (Progressive Care Unit).02/04/2026 Seen and examined no acute distress patient states overall feeling slightly better, blood sugars back in the 400s though this morning augmented insulin basal, continue to monitor likely discharge tomorrow if glucose much more controlled. Continue IV fluids, increase Lantus insulin to 40 units with 10 units preprandial continue sliding scale, will give additional bolus today. 02/05/2026 discharge recommendations: return to long term, care planned treatmentd discharge/discontinue OT treatment evalution complete: Yes. During an interview on 02/06/2026 at 1:25 p.m., the Treatment Nurse said on Thursday, 01/29/2026, Resident #1 told the doctor he was not feeling well. The Treatment Nurse said Resident #1 told the doctor he felt nauseous and his poop smelled bad and asked the doctor if he wanted to test his stool and the doctor said no but ordered some labs. The Treatment Nurse said she filled out the lab sheet and placed it on the lab book, she said the lab usually arrived the next day. The Treatment Nurse said Resident #1 did not request to go to the hospital at that time nor did he appear in distress. The Treatment Nurse said the following day (01/30/2026) after the labs were drawn that the lab normally calls the facility but for some reason they contacted the doctor. The Treatment Nurse stated the physician did not contact the facility. The Treatment Nurse said that on Saturday 01/31/2026 at about 9:30 a.m. Resident #1 asked her about his lab results but told him to ask LVN B because she was his nurse at that time. The Treatment Nurse said she had not witnessed if Resident #1 had asked LVN B about his lab results. During an interview on 02/06/2026 at 2:00 p.m., LVN C said she worked on Monday (02/02/2026) at 6:00 a.m. to 2:00 p.m. shift. LVN C stated she checked on Resident #1 and he was pale and talking differently. LVN C said the resident was awake and alert, so she checked his vital signs, and his blood pressure was high, and Resident #1 asked about his lab results. LVN C said she recalled that Resident #1 had had some labs done so she went to check to see if the results were back. LVN C said she looked at the Ring App and Resident #1's blood sugar was at 945 on his lab results which was at a high critical level. LVN C said she checked Resident #1's blood sugar with their glucometer and it was 478. LVN C said Resident #1 was sent to the hospital. LVN C said she did not understand why the laboratory had not called because whenever there were critical value results, they called to make them aware ASAP. LVN C said she worked on Friday 01/30/2026 when the lab results were done but no one from the laboratory or doctor's office called with the critical values since the doctor was contacted about the critical values around noon. LVN C said, at shift change, she discussed with the night shift what was on the 24-hour report and there was nothing about Resident #1's lab results. (Note: the ring app is an app that is located on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675910 If continuation sheet Page 2 of 5 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 675910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Hogan Park 3203 Sage St Midland, TX 79705 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 0773 Level of Harm - Actual harm Residents Affected - Few nurse's computer, and they can view lab results when they login to the app). During a telephone interview on 02/06/2026 at 3:30 p.m., the NP said if a resident had a critical lab result, it was expected for the facility to contact them. The NP said it also depended on what lab it was because at times it could be treated at the facility. The NP said the blood glucose of 934 was high but, if reported to Resident #1's doctor and not her, she would not know what Resident #1's doctor would do. The NP said Resident #1's doctor needed to be interviewed as to why he had not called the facility to report the high blood sugar result. During an interview on 02/06/2026 at 4:47 p.m., ADON F said efax would send the labs directly to the Ring App and then staff would print them off and fax them to the doctor and called them if there was a critical value. ADON F said any nurse could monitor the app and print the labs from there. ADON F said all the nurses should know about that app and they recently did an in-service to make sure all nurses knew about it. ADON F said they also placed the orders on the 24-hour report. ADON F said they started doing the daily lab tracking log which was also initiated. ADON F said a negative outcome from a person going without treatment for high blood sugar could be a diabetic coma or pass out. During a telephone interview on 02/06/2026 at 5:12 p.m., LVN B said she worked at the facility on the weekend of 31st of January through the 1st of February 2026. She said Resident #1, on Saturday 01/31/2026, complained of feeling nauseous and issues with going to the restroom. LVN B said she gave Resident #1 a fleets enema and medication for nausea. LVN B said Resident #1 was able to go to the restroom and the medication had made him feel better and there had been no problems after that. LVN B said Resident #1 after the treatment had felt better. LVN B said ADON D gave her Resident #1's lab results on 01/31/2026 and told her to fax them to the doctor. LVN B said she did not pay attention to the lab results since it indicated the doctor was already aware. During a telephone interview on 02/10/2026 at 8:48 a.m., the Laboratory Technician said, in case of critical value results, it was their protocol to call the location or doctor who ordered the lab test. The Laboratory Technician said they would fax the orders if they were requested from the facility or doctor's office but did not know about an app that the facility could submit the labs electronically. The Laboratory Technician said she was not sure why the doctor had been contacted about the critical results instead of the facility. The Laboratory Technician said it could have occurred because whatever label was on the test tube would have been the person they notified. During a telephone interview on 02/11/2026 at 1:52 p.m., LVN B said on 01/31/2026 ADON D brought her the lab result from Resident #1 and told her to fax them to the doctor. LVN B said ADON D did not mention anything else besides faxing them to the doctor. LVN B said that she had not reviewed them and only faxed them as she assumed that ADON D had viewed them already and had done something about it. LVN B said she had reviewed the 24-hour report and had not noticed any pending lab orders. LVN B said again that she had not actually viewed the labs that she saw the MD was aware and there were no new orders. LVN B said she assumed ADON D viewed them before he handed them to her and he did not say anything about critical value on the lab sheet. LVN B said a negative outcome to a resident with high blood sugar could be them feeling horrible and going into diabetic ketoacidosis. During a telephone interview on 02/11/2026 at 2:48 p.m., ADON D said that he had worked on Saturday 01/31/2026 and saw on the Ring App there were labs pending and printed them out. ADON D said he printed them out and handed them to LVN B to include in Resident #1's records. ADON D said he told LVN B to either call or contact Resident #1's doctor with the lab results. ADON D said he had not seen the results and had just printed the results out and handed them to each of the nurses. ADON D said if he had seen the critical lab values he would have contacted the doctor himself. ADON D said a negative outcome could have occurred from a critical level of high blood sugar could be that the resident could have passed away. During a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675910 If continuation sheet Page 3 of 5 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 675910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Hogan Park 3203 Sage St Midland, TX 79705 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 0773 Level of Harm - Actual harm Residents Affected - Few telephone interview on 02/10/2026 at 10:05 a.m., The Medical Director said he did not recall if he got a call from the laboratory on Friday 01/30/2026 regarding Resident #1. The Medical Director said normally the facility called him with critical values and they were good at doing that. The Medical Director said he did recall if they sent Resident #1 to the hospital. The Medical Director asked what the critical lab was and was told the glucose of 934 and said he would have sent Resident #1 to the hospital. The Medical Director said the negative outcome could have been several things such as diabetic ketoacidosis. During an interview on 02/12/2026 at 10:56 a.m., the Administrator said she was monitoring the lab reports by looking at them on the TEAMS (A messaging app to communicate with other people). The Administrator said that the ADON or DON would monitor the labs that were coming in from the lab and then they would fill out the lab tracking form on TEAMS. The Administrator said that on 01/30/2026 she was out of the country so the previous DON and ADON were the ones monitoring that. The Administrator said the nurses should have reported the high blood sugar to the doctor and not just assumed the doctor knew about it. The Administrator said if a resident with a critical level of high blood sugar was not treated timely, they could go into a diabetic coma or die. During a telephone interview on 02/27/26 at 9:55 AM, the Medical Director stated that it would be hard to determine if Resident #1 had not gone to the hospital would have resulted in in death. The Medical Director stated he was not sure if sending Resident #1 sooner to the hospital would have prevented harm. The Medical Director stated the nurse should have called him instead of assuming that he was notified and followed the facility policy of notifying him. The Medical Director stated he did not recall getting called by the Laboratory Technician on the critical lab value. The Medical Director stated if he would have recalled or received the call from the Laboratory Technician he would have sent the resident to the hospital and the same if the facility had called him, he would have done the same thing which was send Resident#1 to the hospital. During an interview on 02/27/26 at 4:22 PM, ADON F said it was expected for ADON D to have reviewed the lab report before ADON D handed it to LVN B. ADON F said LVN B should have reviewed the lab report(s) before she faxed or sent the results to the doctor as per facility policy. During a telephone interview on 02/27/26 at 4:42 PM, LVN B said she had sent the lab results to the Medical Director on 01/31/2026. LVN B said she had not received confirmation that the results had gone through. LVN B said she only worked at the facility PRN and was not too familiar with how the facility's process/policy was done regarding faxing/notification of the lab results. LVN B again denied she had reviewed the lab results and denied Resident #1 had ever asked her to read him the lab results. During a telephone interview on 02/27/26 at 5:10 PM, the Medical Director stated that if LVN B had faxed him the results or texted the results it would be impossible for him to remember that. The Medical Director said that there was no way to see if he had received the text back on 01/31/2026 or the fax at his office. The Medical Director stated the facility should have followed there policies. Record review of the facility policy titled, Lab monitoring, dated 05/2021 revealed, in part It is the policy of this community that physician ordered laboratory services will be provided and monitored. All lab results will be reviewed by a nurse. The nurse will date and document the time the result was reviewed. Critical lab results will be called to physician or on-call physician immediately. Initially, date and time of the lab result. Inform the DCO regarding the abnormal lab values. If a reply is needed and there is no reply within 24 hours, you must call the physician's office and notify them of the abnormal value. The physician's office is to be notified daily until there is a response. Record review of the facility policy titled, Lab orders, dated 08/2021, revealed in part, It is the policy of this community to provide or obtain laboratory services to meet the needs of its residents. The community is responsible for the timeliness of the services. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675910 If continuation sheet Page 4 of 5 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 675910 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Hogan Park 3203 Sage St Midland, TX 79705 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 0773 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The community must notify the attending physician of the lab results. The DCO/designee will be responsible for monitoring lab orders to ensure that all ordered labs have been drawn as ordered by the physician. Lab tracking is to be documented daily on the Daily Lab Tracking Form. Ensure that all labs ordered have been collected with results communicated to MD/family in a timely manner. Proof of notification to be included on lab report sheet and/or in the nurse's notes. The EDO must periodically check the lab tracking book on a random basis to ensure DCO/designee is complaint with the process. The attending physician will be notified promptly of lab results. Event ID: Facility ID: 675910 If continuation sheet Page 5 of 5