Inspection·September 30, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of facility policy titled Care Planning- Interdisciplinary Team, revised September 2013, revealed, in part, .the care planning/interdisciplinary team is responsible for development of the individualized comprehensive care plan for each resident . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 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 676204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Cedar Bayou 2000 W Baker Road 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain medical records that are complete for 6 of 6 sampled residents (Residents #37, #34, #33, #41, #49, #39) in that: Weekly weights were not kept for 6 of 6 (Residents #37, #34, #33, #41, #39, #49) new admitted residents per facility policy. This failure places residents who are newly admitted or with unplanned significant weight loss/gain at risk for not having their nutrition needs re-assessed and met in a timely manner. Findings included: Record review of Resident #37's face sheet revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with a tracheostomy status, gastrostomy status and acute respiratory failure. Record review of Resident #37's weight records, dated 09/30/2021, revealed resident was first weighed on 09/07/2021 at 154.2lbs. No other weights were documented on the EHR. Record review of Resident #34's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with hypothyroidism and Chron's disease. Record review of Resident #34's weight records, dated 09/30/2021, revealed resident was first weighed on 09/07/2021 at 260lbs. No other weights were documented on the EHR. Record review of Resident #33's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with diabetes melitus, dysphagia and GERD. Record review of Resident #33's weight records, dated 09/30/2021, revealed resident was first weighed on 09/07/2021 at 112lbs. No other weights were documented on the EHR. Record review of Resident #41's face sheet revealed an [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with a chronic obstructive pulmonary disease and diabetes melitus with diabetic neuropathy. Record review of Resident #41's weight records, dated 09/30/2021, revealed resident was first weighed on 09/07/2021 at 184.6 lbs. No other weights were documented on the EHR. Record review of Resident #39's face sheet revealed an [AGE] year-old male who was admitted into the facility on [DATE], and was diagnosed with respiratory failure and hypertensive heart disease. Record review of Resident #39's weight records, dated 09/30/2021, revealed resident was first weighed on 09/07/2021 at 188.6lbs. No other weights were documented on the EHR. Record review of Resident #49's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE], and was diagnosed with adult failure to thrive, dehydration and dysphagia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 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 676204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Cedar Bayou 2000 W Baker Road 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 0842 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #49's weight records revealed resident was first weighed on 09/09/2021 at 99.2lbs and on 09/16/2021 at 99.2lbs, indicating the resident missed two opportunities for weekly weights. In an interview with the DON on 09/29/2021, at 3:35PM, she stated per facility policy, residents are to be weighed upon admission and once every week during their first four weeks to watch for weight changes. Residents Affected - Some Record review of August - September 2021 Weekly weights and New Admits revealed weights for residents #33, #37 and #39 were documented incorrectly. Resident #33's weights were recorded as follows: 8/31/21 112lbs, 8/7/21 - 112.5lbs, 8/14/21 - 112lbs, 8/21/21 - 112lbs. Resident #37's weights were recorded as follow: 8/31/21 - 152.4lbs, 9/7/21 - 153lbs, 8/14/21 - 153lbs, 8/21/21 - 153.6lbs. Resident #39's weights were recorded as follow: 8/31/21 - 188.6lbs, 9/7/21 - 189lbs, 8/14/21 - 189lbs, 8/21/21 - 190lbs. This indicated that weights that were written by the restorative aide were incorrect given that weights were documented on dates in which residents were not yet in the facility. And weights written on 9/7/21 did not match weights that were entered on the EHR for residents #33, #37 and #39. In an interview with the restorative aide on 09/30/2021 at 10:27AM, she stated she wrote down some residents weights on her personal scratch paper and wrote some of those weights on the weekly weight document but she does not put weights on to the computer because that is how the DON wants the weight recorded. She stated she just wrote the weekly weights in for resident #37 , #33 and #39 when it was asked for by the surveyor, but when asked where the weights were previously documented, she stated she does not know where it was documented and showed only scratch paper (not dated but) reflecting admission weights for Resident #33 and Resident #37. When asked for additional written weight records for the following weeks on the residents, she stated she does not have them and that the DON she should have them. In an interview with the DON on 09/30/2021 at 10:39AM, she stated she had the restorative aide write weekly weights on the weekly weight documents for new admissions and she is to review them weekly to assess for weight changes prior to handing the records back to the restorative aide. When asked for weekly weight records on residents #37, #33, and #39 she stated she had no additional weights outside what was recorded in the record, August - September 2021 Weekly weights and New Admits In an interview with the DON on 09/30/2021 at 11:16AM, she stated the Restorative Aide was supposed to take records weights on Wednesdays, that being the reason some residents admission weights were not taken until a week after admission. She stated their weights are supposed be taken within the first two days of admission and she will have to let the restorative aide know when a new resident comes in. She also stated she was supposed to receive the weekly weights every week, but she did not receive the weights from the restorative aide for the past two weeks, so she was not able to monitor whether the resident's weights were being checked. She said the restorative aide also told her that she works on the floor a lot and she does not have time to document the residents' weights as regularly as she is supposed to. The DON stated she needed a better method to ensure weekly weights for new admits are checked and documented. Record review of facility's weight policy, not dated, stated, .Complete weekly weights on the following: new and readmits for four weeks and on residents weighing less than 100 pounds. Record review of facility's policy on Charting and Documentation, dated July 2017, revealed, .All (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 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 676204 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Focused Care at Cedar Bayou 2000 W Baker Road 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 0842 Level of Harm - Minimal harm or potential for actual harm services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 5 of 5