Inspection·December 2, 2022

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with MDS coordinator on 11/29/22 at 3:00 PM MDS coordinator, she stated Resident #13 was contracted on both hands. No answer was given for not coding Resident # 13 correctly on her Annual MDS assessment. She said she would correct the MDS assessment and send it in. 2. Review of Resident #20's face Sheet, dated 11/30/22, revealed she was a [AGE] year-old female, admitted to the facility on [DATE], with the following diagnoses: paranoid schizophrenia ( a form of mental illness), fracture of right radius, muscle weakness, lack of coordination, osteoarthritis (Joint pain and stiffness) , and repeated falls. Review of the admission MDS assessment, dated 09/01/22, revealed Section A-1510 for mental illness was left blank indicating that Resident # 20 did not have the diagnoses of mental illness. Review of Resident #20's PASARR screening (PL1), dated 08/25/22 revealed Resident #20, was positive for Mental illness (MI). Review of Resident #20's consolidated Physician's Order report, dated 11/27/22, revealed an order for Risperdal 0.5mg by mouth 2 times a day for schizophrenia (type of mental illness). Record review of Resident #20's admission records from a local hospital, dated 08/13/22 revealed a diagnosis of depression and psychiatric disorder. 3 Review of Resident #38's face Sheet, dated 11/30/22, revealed he was a [AGE] year-old female, admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease, type 2 diabetes, muscle weakness and heart failure. Record Review of Resident #38's MDS admission assessment dated [DATE] revealed section L on oral denture status was coded as none of the above indicating he had all his natural teeth. Record review of Resident #38's diet orders dated 11/17/22 revealed Resident #38 was on mechanical altered diet. Observation and interview on 11/29/22 beginning at 12:00 PM, revealed Resident #39 was having his lunch. He was on mechanical altered diet. During an interview at this time, he stated he had 3 teeth on his upper oral cavity and two on his lower oral cavity that does not fits, and he cannot chew on any solid food. Resident #39 stated he does what he can with what he had. Resident #39 stated he can eat soft food and would like to see a dentist if he could but it had not been discussed at the facility. During an interview with MDS Coordinator on 11/30/22 at 11:45 AM, MDS Coordinator she stated she was responsible for completing the MDS for all the residents and insuring the MDS reflected Resident's conditions. MDS Coordinator She gave no answer as to why the MDS assessment did not reflect Resident's condition. MDS coordinator stated she completes all assessment by gathering information from all disciplines. MDS Coordinator She stated she would revisit the identified residents and complete an amendment. Review of the facility's policy on accuracy of MDS assessments was requested prior to exit on 12/01/22. The MDS coordinator stated she uses the RIA Manual. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 2 of 11 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 12/02/2022 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the CMS RAI Version 3.0 Manual dated October 2019, reflected in part, the RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care pln. It also assists staff with evaluation goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident's status. An RAI must be completed for any resident residing in a facility including short-term and respite residents residing for more than 14 days. Event ID: Facility ID: 676204 If continuation sheet Page 3 of 11 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 12/02/2022 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 (Resident #20) reviewed for PASARR. Resident #20 with diagnoses of mental illness did not receive a PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Review of Resident #20's face sheet, dated 11/30/22, revealed Resident #20 was a [AGE] year-old female, admitted to the facility on [DATE], with the following diagnoses: paranoid schizophrenia (Type of Mental illness) , fracture of right radius, muscle weakness, lack of coordination, and repeated falls. Review of Resident's 20's admission MDS assessment, dated 09/01/22, revealed Section A-1510 was left blank which reflected that Resident #20 was not assessed for mental illness on her admission MDS. Review of Resident #20's PASARR Level I screening (PL1), dated 08/25/22 revealed Resident #20, was positive for Mental illness (MI). Review of Resident #20's clinical record revealed there was no evidence that Resident #20 had a PASARR Level II Screening (PE). Review of Resident #20's consolidated physician Orders Report, dated 11/27/22, revealed an order for Risperdal 0.5mg by mouth 2 times a day for schizophrenia. In an interview, on 11/30/22 at 3:25 PM, MDS Coordinator stated she was responsible for PASARR screening and updating Resident's assessment. MDS Coordinator stated Resident #20 was not diagnosed with mental illness. MDS Coordinator reviewed Resident #20's diagnoses and stated it was overlooked. MDS Coordinator stated she would update the MDS and refer Resident #20 for PASRR evaluation. Review of Facility's policy on ensuring that PASRR evaluation for residents with positive PASRR on admission, was requested from the Administrator. on 11/30/22 at 4:30pm. The document provided was an information letter no. 30-41 dated 9/29/20 from Texas Department of health and Human services relating to the use of telephone interview and video conferencing . The facility Administrator stated that the document was all she had. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 4 of 11 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 12/02/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means and received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #13) reviewed for gastrostomy tube management. - LVN B failed to follow Resident #13's physicians orders and facility policy by dissolving medication for administration in 20-30 ml of water instead of 5 ml. - LVN B failed to check for placement prior to use of Resident #13's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach) by injecting 30 ml of water by syringe instead of air and failing to listen for bowel sounds. - LVN B failed to flush Resident #13's G-tube correctly by injecting 30 ml of water by force using a syringe instead of allowing the water to flow by gravity. - LVN B failed for follow Resident #13's physicians orders and facility policy by flushing with 30 ml of water between each medication instead of 5- 10 ml. These failures could place residents who have a g-tube, at risk for adverse reactions, inadequate therapy, and a decreased quality of life. Findings Include: Record review of Resident #13's face sheet dated 12/01/22 revealed,. a 70-yearr-old female admitted to the facility with diagnoses which included: gastrostomy status, hypertension, and tracheostomy (a surgical hole made through the neck into the windpipe to assist in breathing). Hypotension was not listed as one of Resident 13's diagnoses. Record review of Resident #13's Annual MDS dated [DATE] revealed, moderately impaired cognitive skills for daily decision making, total dependence on most ADLs, always incontinent of bladder and ostomy status. Record review of Resident #13's undated care plan revealed, focus- resident requires tube feeding related to swallowing problem; interventions- check for tube placement and gastric contents/residual volume per facility protocol. Record review of Resident #13's Physician's Order dated 03/25/22 revealed, flush tube with 30 cc before and after meds and give 5-10 ml of water between each medication. An observation on 12/01/22 beginning at 08:12AM revealed, LVN B preparing medication for administration to Resident #13. LVN B retrieved 9 solid forms and 2 liquid medications for Resident #14 in a individual medication cups, she crushed each solid form individually, returned them into their medication cups and entered into Resident #13's room. At 08:12AM she suspended each medication in 20-30 ml of water and then stirred each medication. LVN B then drew up 30 ml of water in a syringe and stated I am going to check for placement, attached the water filled syringe to Resident #13's G-tube, injected the water into the resident's G-tube and immediately pulled out residual fluid. After (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 5 of 11 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 12/02/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few returning the residual (the volume of fluid remaining in the stomach) into the resident's G-tube. LVN B removed the plunger and administered the suspended medications with a 30 ml flush between each medication. In an interview on 12/01/22 at 11:25 AM, the ADON said that prior to administering medication via g-tube nursing staff must first verify the G-tube flush orders as well as the medications. She said medication should be suspended in just enough water to dissolve the medication, no more than 10 ml. LVN B should not have used 20-30 ml because administering too much water could lead to fluid overload in Resident #13. The ADON said once the medication has been prepared, nursing staff must then check for placement through auscultation (listening to sounds with a stethoscope, by injecting are into the resident's stomach while listening for bowel sounds. She said she would not have used injected water without auscultation/checking placement or use force to inject water into a resident's G-tube because, failing to check for placement prior to G-tube use could result in the injected substance entering into cavities outside of the stomach, and pushing water via the syringe could result in damage to the resident's G-tube. The ADON said failure to check for placement and flush G-tubes correctly could place resident's at risk for injury. In an interview on 12/01/22 at 11:32 AM, LVN B said crushed medication for administered via G-tube should first be dissolved in 15-20 ml of water and a flush of 10-15 ml of water should be performed between each medication during administration. She said she used 20-30 ml of water to dissolve the medications and performed a 30 ml flush in between each of Resident #'13's medication due to her miscalculation and that the use of too much fluid during medication administration could result in fluid overload in the resident. LVN B said prior to administering medication via G-tube nursing staff are expected to check for placement by injecting 10 cc of air into the tube while listening for bowel sounds and she didn't know why water could not be used. She said she did not know why she pushed 30 ml of water by force through the syringe and pulled the residual prior to medication administration to Resident #13. LVN B said failure to check for placement prior to medication administration could result in the contents of the syringe not going into the stomach and instead leaking into the surrounding area resulting in adverse reactions. LVN B said she did not know water could not be pushed by force through a syringe during G-tube administration. Interview on 12/01/22 at 12:10 PM ADON stated there was no specific policy for checking placement/residual for a resident G-tube. Record review of the facility policy dated 04/20 revealed,3- Enteral tubes are flushed with at least 5 ml of water before administering medications, between each medication, and after all medications have been administered .5- Each medication is administered separately to avoid interaction and clumping . Tablets, powders, and beads (never crushed) from open capsules, are mixed with 5 ml of water prior to administration via the tube. In an interview on 12/01/22 at 12:10 PM the ADON said there was no specific policy for checking placement/residual for a resident G-tube. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 6 of 11 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 12/02/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and record review the facility failed to assure that there was sufficient qualified nursing staff available at all times (24-hours). Residents Affected - Some The facility failed to provide 24-hour licensed nursing (registered nurse) coverage November 21 - 26 and November 28th and 29th of 2022. This failure could place residents at risk of not receiving related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. Findings: Interview on 11/28/22 at 08:45 AM Administrator stated that there was no licensed nursing coverage at the facility. The facility's DON was out of the country on vacation from November 21st until the after the 1st of the year. Interview on 12/01/22 at 12:43 PM Administrator stated that she does not have a waiver for licensed nursing coverage to cover the dates of November 21, 22, 23, 24, 25, 26 , 28, and 29th of 2022. Interview on 12/02/22 at 11:18 AM Administrator stated that the facility does not have a staffing policy for licensed nursing coverage. Record review Registered Nurse (RN) staffing coverage calendar dated November 2022 showed that the facility did not have 24-hour RN coverage for November 21, 22, 23, 24, 25, 26, 28, and 29 of 2022. Record review Resident Rights undated . Your rights include but are not limited to: 1. All care necessary for you to have the highest possible level of health; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 7 of 11 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 12/02/2022 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 4 residents (Resident #3 and Resident #22) reviewed for pharmaceutical services. - The facility failed to administer medications to Resident #3 correctly by crushing and administering multiple pills together. - The facility failed to administer BP medication to Resident #22 as ordered by administering Midodrine (a medication for increasing low blood pressure) outside of physician ordered parameters. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings included: Resident #3 Record review of Resident #3's face sheet dated 12/01/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Alzheimer's, dysphagia (difficulty swallowing), cognitive communication deficit, shortness of breath and high blood pressure. Record review of Resident #3's undated care plan revealed, Focus- anticoagulant therapy related to history of a stroke, Intervention- administer blood thinner as ordered by physician. Resident #3's care plan did not include a focus area for her dysphagia. Record review of Resident #3's Quarterly MDS dated [DATE] revealed, use of corrective lenses, moderately impaired cognitive skills for daily decision making, extensive assistance with most ADLs, use of a wheelchair and always incontinent of both bladder and bowel. Record review of Resident #3's Physician's Order dated 07/18/18 revealed, Docusate 100 mg- give 1 tablet by mouth once daily for constipation. Record review of Resident #3's Physician's Order dated 06/30/22 revealed, Eliquis 5mg- give 1 tablet by mouth two times a day for DVT (blood clot). Record review of Resident #3's Physician's Order dated 07/03/22 revealed, Crush Meds every shift. The order did not state that the medications could be crushed and administered together. Record review of Resident #3's Physician's Order dated 11/20/22 revealed, Furosemide 40 mg- give 1 tablet by mouth two times a day for diuretic. Record review of Resident #3's Order Summary dated 12/01/22 revealed, Resident #3 had no order to administer crushed medications together. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 8 of 11 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 12/02/2022 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 0755 Level of Harm - Minimal harm or potential for actual harm An observation on 12/01/22 beginning at 08:47 AM revealed, LVN A was preparing medication for administration to Resident #3. LVN A retrieved 1 tablet of Furosemide 40mg, 1 tablet of Eliquis 5mg and 1 tablet of Docusate 100 mg, placed all 3 tablets in a single pouch, crushed them all together and mixed them in pudding. At 08:52 AM, LVN A entered Resident #3's room and administered the medication to the resident. Residents Affected - Some In an interview on 12/01/22 at 11:48 AM, LVN A said that medications must be placed in separate containers, crushed separately, mixed individually in pudding and then administered separately. He said medications should not be crushed together because there is a change in the chemical structure. LVN A said when he administered medications to Resident #3 he forgot the medications should be crushed and administered separately. He said crushing medications together could lead to toxicity and place the resident at risk of not getting the desired therapeutic effect. In an interview on 12/01/22 at 11:25 AM, the ADON said when crushing medication for administration, nursing staff are expected to crush each medication individually and administer them separately it the preferred vehicle (pudding/apple sauce or jelly). She said medications should not be crushed together because once crushed the chemicals might not mix well and administering the medication together could place residents at risk of not receiving the desired therapeutic effect. Record review of the facility policy Crushing Medications effective 11/01/19 revealed, 6- Each medication must be crushed and administered separately. Crushed medications should not be combined and given all at once. If the resident requires that crushed medications be administered together; a- A physician's order is required to crush and administer crushed medications together with the order clearly stated on the MAR; b- Approval must be obtained from resident. Family and/or responsible party if the resident requires to have their medications crushed and administered together; c- The care plan must reflect the resident's requirements to have all crushed medications administered together. Resident #22 Record review of Resident #22's face sheet dated 12/01/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: acute kidney function, depression, heart failure and hypotension. Record review of Resident #22's Quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13 out of 15, use if a walker, independence with most ADLs, occasionally incontinent of bladder and an ostomy. Record review of Resident #22's undated care plan revealed, the care plan did not address the resident's hypotension. Record review of Resident #22's Physician's Order dated 03/16/22 revealed, Midodrine 5 mg- Give 1 tablet by mouth every 8 hours for hypotension GIVE MED IF BP LESS THAN 100/55. Record review of Resident #22's MAR dated November 2022 revealed, Resident #22 received Midodrine 5 mg outside of parameters of <100/55 and received it 22 times in the month of November documented as followed: 11/02/22 at 07:00 AM- BP 111/72 by MA A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 9 of 11 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 12/02/2022 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 0755 11/03/22 at 11:00 PM - BP 112/69 by Agency Staff #1 Level of Harm - Minimal harm or potential for actual harm 11/04/22 at 11:00 PM- BP 132/77 by Agency Staff #1 11/06/22 at 07:00 AM- BP 119/72 by MA A Residents Affected - Some 11/08/22 at 07:00 AM- BP 129/81 by MA A 11/08/22 at 11:00 PM- BP 125/76 by LVN C 11/09/22 at 03:00 PM- BP 122/75 by MA A 11/10/22 at 11:00 PM- BP 140/72 by Agency Staff #2 11/11/22 at 07:00 AM- BP 119/79 by MA A 11/13/22 at 07:00 AM- BP 110/71 by MA A 11/16/22 at 11:00 PM- BP 118/83 by LVN C 11/17/22 at 07:00 AM- BP 142/85 by MA A 11/17/22 at 11:00 PM- BP 117/75 by LVN C 11/18/22 at 11:00 PM- BP 108/74 by LVN C 11/20/22 at 07:00 AM- BP 123/80 by MA A 11/21/22 at 07:00 AM- BP 124/89 by MA A 11/22/22 at 03:00 PM- BP 143/74 by the ADON 11/23/22 at 07:00 AM- BP 155/89 by MA A 11/24/22 at 07:00 AM- BP 121/74 by MA A 11/27/22 at 11:00 PM- BP 143/97 by Agency Staff #3 11/28/22 at 11:00 PM- BP 111/45 by LVN C 11/30/22 at 03:00 PM- BP 128/78 by the ADON 11/30/22 at 11:00 PM- BP 115/83 by LVN C An observation and interview on 12/01/22 beginning at 07:52 AM revealed, MA A preparing medication for administration to Resident #22. MA A entered into Resident #22's room and checked her blood pressure which resulted in 150/82 with a HR of 75. MA A returned to her medication cart and retrieved 1 tablet of Midodrine 5mg with prescriber instructions to administer for blood pressure readings < 100/55 as well as thirteen (13) other solid forms into a medication cup and entered the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 10 of 11 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 12/02/2022 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some room to administer the medication. Before MA A could administer the medication, this surveyor stopped MA A and alerted her to the blood pressure being outside of parameters for administration. MA A stated Midodrine was being administered to Resident #22 due to her low blood pressure, but she gets confused by the medication orders regularly because it gives instructions of when to administer the medication instead of when to hold the medication. MA A stated when an elevated blood pressure was entered into the EMR the system did not provide instructions to hold the medication and looking back , she remembered she had frequently administered the medications at BP reading above 100. MA A stated administering Midodrine to a patient with high blood pressure could further increase the resident's blood pressure. In an interview on 12/01/22 at 11:25 AM, ADON stated prior to administering medications to a resident nursing staff are expected to verify the orders and in the case of blood pressure was to verify the collected blood pressure against the order parameters. ADON stated Midodrine was used to treat hypotension and should only be administered below a BP reading of 100. ADON stated if a resident had an elevated BP, the medication must be held and administering Midodrine outside of parameters could place residents at risk of increased blood pressure, irregular heart rate, stroke, or a hypertensive emergency. Record review of MA A'S medication administration competency assessment dated [DATE] revealed, eight (8)- medications were administered in accordance with current physician's order reflecting; yes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676204 If continuation sheet Page 11 of 11