Health inspection·June 26, 2024

F 0755 - Atorvastatin Calcium Oral Tablet 40 MG - Give 1 tablet by mouth at bedtime related Level of Harm - Minimal harm or potential for actual harm to HYPERLIPIDEMIA, UNSPECIFIED, start date of 04/17/23 - Melatonin Oral Tablet 3 MG - Give 3 mg by mouth at bedtime for insomnia, start date of 04/18/23 Residents Affected - Few - traZODone HCl Oral Tablet 50 MG - Give 2 tablet by mouth at bedtime related to UNSPECIFIED MOOD [AFFECTIVE] DISORDER (F39);SLEEP DISORDER, UNSPECIFIED (G47.9);ANXIETY DISORDER, UNSPECIFIED, start date of 10/13/24 - Brilinta Oral Tablet 90 MG (Ticagrelor)- Give 1 tablet by mouth two times a day for Atrial Thromboembolism, start date of 04/18/23 - Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) - Give 250 mg by mouth two times a day related to UNSPECIFIED MOOD [AFFECTIVE] DISORDER (F39), start date of 09/06/23 - Famotidine Tablet 20 MG - Give 1 tablet by mouth two times a day for GERD, start date of 07/15/23 - Gabapentin Oral Capsule 100 MG -Give 1 capsule by mouth two times a day for pain, start date of 03/28/23 - Lovaza Oral Capsule 1 GM (Omega-3-acid Ethyl [NAME]) - Give 2 capsule by mouth two times a day for supplement, start date of 06/09/23 - Metoprolol Tartrate Tablet 25 MG - Give 0.5 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold B/P less than 100/60 or HR less than 60, start date of 04/18/23 - Sacubitril-Valsartan Oral Tablet 49-51 MG (Sacubitril-Valsartan) - Give 0.5 tablet by mouth two times a day for HTN HOLD IF SBP less than 110, start date of 04/19/23 Record review of Resident #2's face sheet, printed on 06/26/24, revealed a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, cognitive communication deficit, pain in unspecified shoulder and hypotension. Record review of the physician orders tab of Resident #2's electronic health record revealed the following evening orders: - Neurontin Oral Capsule 300 MG - Give 300 mg by mouth at bedtime related to CHRONIC PAIN SYNDROME, start date of 05/01/24 - Senna-Docusate Sodium Tablet 8.6-50 MG - Give 1 tablet by mouth at bedtime for constipation, start date of 08/14/22 -Zoloft Oral Tablet 25 MG (Sertraline HCl) - Give 3 tablet by mouth at bedtime for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 2 of 4 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 Dysthymia, start date of 05/08/24 Level of Harm - Minimal harm or potential for actual harm -Depakote Oral Tablet Delayed Release125 MG (Divalproex Sodium) - Give 1 tablet by mouth two times a day for Anxiety and agitation, start date of 05/08/24 Residents Affected - Few - Memantine HCl Tablet 5 MG - Give 1 tablet by mouth two times a day related to ALZHEIMER'S DISEASE, start date of 08/14/22 - Gabapentin Capsule 100 MG - Give 1 capsule by mouth three times a day for neuropathic pain, start date of 08/14/22 - Midodrine HCl Tablet 5 MG - Give 2 tablet by mouth three times a day for hypotension 1 hour before Dialysis Hold for BP of greater than 120/90, start date of 08/16/22 - Renvela Oral Tablet 800 MG (Sevelamer Carbonate) - Give 1 tablet by mouth with meals for related to END STAGE RENAL DISEASE, start date of 03/07/24 In a telephone interview on 06/24/24 at 3:49 p.m., Resident #1's family member stated on 06/02/24, Resident #1 was provided the incorrect medications by LVN A when he went on therapeutic leave. The family member stated they received several calls after he left from LVN A, stating Resident #1 was given another residents medications and not to take the medications provided. The family member stated Resident #1 was not provided his insulin as well. The family member stated the medications were not double checked at the facility because they were in a rush. The family member stated Resident #1 did not take any of the medications provided to Resident #1 when he left the facility. In an interview on 06/25/24 at 1:16 p.m., Resident #1 stated he did not recall an instance where he was provided another residents medications or that he received a call stating he was provided another residents medications. Resident #1 stated he had no concerns regarding his medications. In an interview on 06/25/24 at 2:50 p.m., LVN A stated she was Resident #1's nurse when he went on therapeutic leave on 06/02/24. LVN A stated she recalled having to call Resident #1's family member to report the incorrect medications. LVN A stated MA B prepared the medications for Resident #1's leave, which she provided to the resident as his family member signed him out of the facility. She stated roughly 30 minutes after his departure, MA B notified her that she had prepared Resident #2's medication for Resident #1 in error. LVN A stated she immediately began to call Resident #1 and his family member to report the error. LVN A stated when she was able to speak with Resident #1's family member, she was able to confirm he did not take the medications. LVN A stated she offered to prepare Resident #1's evening medications, but the family member declined to pick them up. LVN A stated if Resident #1 would have taken the medications, they could have had adverse effects to the resident. LVN A stated she reported the situation to LVN C, who was the supervisor, and he took over the situation. LVN A stated by her next shift, which was the following weekend, she was in serviced on medication administration and leave of absence medication procedures. In a telephone interview on 06/26/24 at 10:51 a.m., MA B stated LVN A notified her on the morning of 06/02/24 to prepare the evening medications for Resident #1, but she heard Resident #2, whose names were similar. MA B stated she prepared the medications, gave them to LVN A a little after lunch and continued to administer medications to her assigned halls. MA B stated roughly 30 minutes later she saw Resident #2 in the facility, and she immediately realized her error and reported to LVN A. MA B stated LVN A stated she would call Resident #1's family and report to the supervisor. MA B stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 3 of 4 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 675579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beacon Harbor Healthcare and Rehabilitation 6700 Heritage Parkway Rockwall, TX 75087 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 - Few she was not certain how the medications would have affected Resident #1, but she knew Resident #2 had a kidney medication that Resident #1 was not on, so she believed it could have harmed him. MA B stated she had an one-on-one in-service with the DON when she returned to work regarding medication administration, the 10 rights of medication administration and leave of absence medication procedures. Telephone interviews were attempted with the weekend supervisor, LVN C on 06/26/24 at 11:00 a.m., 11:23 a.m., 1:28 p.m., and 3:30 p.m., but were unsuccessful. In an interview on 06/26/24 at 1:33 p.m., the DON stated Resident #1's family member reported the incident to him roughly a week and a half prior to the investigation. The DON stated Resident #1's family member saw him in the facility the week of Father's Day and told him she wanted to speak with him, but she did not have time to speak at that moment. The DON stated about a week later he saw the family member again in the facility and she reported the wrong medications were provided on 06/02/24. The DON stated the family member had the medications with her and he was able to confirm they were the medication of Resident #2, and the medications were destroyed. The DON stated he conducted one-on-one in services with LVN A, MA B, and LVN C regarding incident reporting, medication administration, the 10 rights of medication administration, leave of absence medication procedures and documentation. The DON stated he also in serviced all nursing staff on the 10 rights of medication administration, incident reporting and leave of absence medication procedures. In an interview on 06/26/24 at 2:47 p.m., the ADMIN stated he was aware of the medication mix-up with Resident #1. He stated after the family member reported the incident to the DON, he investigated and found there was a miscommunication between LVN A and MA B. The ADMIN stated staff were able to identify the error and avoid a medication diversion. The ADMIN stated the DON immediately re-trained the involved staff and in-serviced all nursing staff on medication administration, the 10 rights of medication administration, incident reporting, leave of absence medication procedures and documentation to ensure the situation did not occur again. The ADMIN stated the medications could have harmed Resident #1 if had taken them. Record review of Inservice documentation dated 6/22/24 through 6/24/24, revealed all nursing staff, including LVN A, MA B, and LVN C were in serviced on the 10 rights of medication administration, leave of absence medication procedures and incident reporting. Record review of the facility's policy entitled Medication Administration, revised in 02/2007, read in part: POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician . 2. Medications must be administered in accordance with the written orders of the attending physician . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675579 If continuation sheet Page 4 of 4