Inspection·November 3, 2023

F 0757 Level of Harm - Minimal harm or potential for actual harm tablet by mouth one time a day every day for inappropriate sexual behavior, ordered and electronically signed by [Physician A]. Record review of Resident #1s clinical record revealed there was No behavior monitoring nor side effect monitoring logs were found. Residents Affected - Some Review of Resident #1s MAR sheets revealed The Provera was documented as administered on the medication administration sheet from 10/14/23 to 11/03/23. Record review of a consent witnessed by the DON and the ADON on revealed the consent did not inform the family of side effects of the Provera. Review of information from the Federal Drug Administration (FDA revealed the following in part: Provera is a progesterone derivative used to treat abnormal uterine bleeding, prevent pregnancy, paraphilia (a condition typically involving extreme or dangerous sexual activities) .The recommended dose is 5-10 mg daily. It lowers testosterone levels and sexual drive. It has been used in younger patients including pedophiles and individuals with mental illness and sexually inappropriate behaviors. Record review of a progress note written by the DON on 10/09/23 at 12:45 PM revealed the Resident was informed of an order for conjugated estrogen by Physician A on 10/09/2023 which documented the family was notified of the new order and told the resident would have to be discharged if the hormone did not eradicate Resident 31's sexually in appropriate behaviors. An interview on 11/02/2023 at 11:30 AM, with Resident #1's family member revealed she had consented to the Provera for her relative because she was afraid, he was going to be forced to move from the facility if he continued to have inappropriate sexual behaviors with staff and other residents. She stated he needed to stay at the facility because it was close, and his family could visit him. She stated she felt as if it was taking the medication or get kicked out of the facility. She stated she had not been informed of the side effects of Provera by the facility. An interview with Resident #1 on 11/03/2023 at 3:00 PM revealed he had no recollection of sexually inappropriate behaviors with staff or other residents. In an interview on 11/03/2023 at 1:30 PM, the DON said they had received a verbal consent for Provera from Resident #1's Family Member. She said that was who they received all the consents for Resident #1 from. She said they did not get consents for any type of treatments, medications, or care planning from Resident #213, they only received consents from Family Member. She stated there was no documentation for side effect monitoring believed she did not have to even get a consent for this type of medication. In an interview on 1103/32/20232 at 10:00 AM, the DON said they had not tried any non-pharmacological interventions for Resident #1 other than one on one after the incidents. The DON said the intended action of Provera to male residents was it would lower the testosterone levels which would lower their sex drive. In an interview on 1103/0325/20231 at 4:24 PM, Physician A said he treated Resident #1 for health conditions and behaviors, which included sexual behaviors. He said he was aware of orders given by Resident #1's Neurologist for the Provera and it was not intended for long term use. He stated eventually the residents dementia would progress, and the Provera would not be needed as he became less (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 2 of 3 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 675042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seymour Rehabilitation and Healthcare 1110 Westview Dr Seymour, TX 76380 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 0757 mobile. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy that was provided on unnecessary meds was titled, Psychotropic Meds, documented [in-part]: Each resident's drug regimen must be free from unnecessary drugs. Each residents drug regimen will be monitored for dosage, duration of use, indications for use, and presence of adverse effects. Each resident will receive the lowest dose for the shortest period of time to improve the target symptoms being monitored. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675042 If continuation sheet Page 3 of 3