Health inspection·April 20, 2023

F 0756 Resident #12 had the following interventions listed: Level of Harm - Minimal harm or potential for actual harm -11/1/22 My Pharmacist recommended a GDR of my Seroquel. My (NP) reviewed and declined my GDR due to me not being stable and another medication of mine was increased. Date Initiated: 11/02/2022 LPN RN Residents Affected - Few -12/21/22 my pharmacy recommended a GDR of my Seroquel. My (NP) LPN reviewed and approved the recommendation. Date Initiated: 12/21/2022 RN -4/5/23 my pharmacy recommended to attempt a GDR of Seroquel. My NP viewed the recommendation and approved it ordering to discontinue Seroquel. My RP was made aware but refuses a GDR at this time as I have been verbally aggressive at times, and she is concerned that it will worsen without my Seroquel. My Pharmacist and NP are aware. Date Initiated: 04/05/2023 -My nurse/CMA administers Seroquel as ordered by my doctor. My nurse monitors me for: Target behaviors: frightful distress, paranoia, and fearfulness. Side effects: dizziness, fatigue, drowsiness. My nurse reports to my doctor as appropriate. Monitor frequently, re-orientate as necessary, anticipate needs, provide incontinent care every 2 hours and prn Date Initiated: 09/21/2022 Revision on: 10/23/2022 Record review of Resident #12's Order Summary Report, dated 12/21/22 revealed, Seroquel Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth one time a day related to unspecified dementia without behavioral disturbance. Start date of 12/21/22 ordered by (Medical Director). In an interview on 04/20/23 at 05:00 p.m., DON stated she is the one who gets the GDR (Graduated Dose Reduction) and acts on it (doctor notification). She stated that antipsychotics should not be given to a resident with the diagnosis of dementia or Alzheimer's. DON stated they need to consider a whole outlook of the resident (mental, physical, spiritual, etc.) and do not want any resident on unnecessary medications. DON stated the negative outcome of giving a resident who has the diagnosis of dementia or Alzheimer's an antipsychotic for dementia or Alzheimer's could be adverse side effects. DON stated Medical Director, does not order antipsychotics. DON stated NP (mental health) is the one who orders antipsychotics. DON stated Resident #12's family pushes back whenever there is a GDR. They think she is doing well on what she is getting. DON stated she tried to explain if the GDR does not work, they can always go back, but they needed to try. DON stated if they are adamant, then NP was notified, and they try to work with the family. Attempted telephone interview on 04/20/23 at 05:45 p.m., Medical Director, who wrote the order for Seroquel for dementia without behaviors for Resident #12. There was no answer. A voicemail left. No return call was placed by Medical Director. Attempted telephone interview on 04/20/22 at 05:50 p.m., with pharmacist for facility. There was no answer. A voicemail left. In a telephone interview on 04/20/23 at 05:55 p.m., the facility pharmacist stated when she sees an antipsychotic ordered with dementia diagnosis, without behaviors, she will ask for diagnosis to be verified. The facility pharmacist stated the GDR will have it on the paperwork. The facility pharmacist stated antipsychotics need to be tapered before they are discontinued. The facility pharmacist stated the facility sent her an email that the family (of Resident #12) declined the GDR of Seroquel. She stated her notes show the psychiatrist was aware of family declining the GDR. When the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676214 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 676214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076 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 0756 Level of Harm - Minimal harm or potential for actual harm pharmacist was asked what the negative outcome of a resident with dementia without behaviors receiving Seroquel, an antipsychotic, could be, the facility pharmacist replied, The thing as with any antipsychotic, residents are on the lowest dose anyway. There are side effects with any medication. We just try to discontinue by tapering off first. The facility pharmacist stated she already has it on her schedule to send the GDR back to the doctor in July. The facility pharmacist stated it was all she could do. Residents Affected - Few Record review of facility's policy on Antipsychotic Medication Use 2001 MED-PASS, INC (Revised December 2016), revealed: Policy Statement Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation and Implementation 1.Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 7. Antipsychotic medications shall generally be used for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia 8. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms prevent a danger to the resident or others; AND: 1. The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or 2. Behavioral interventions have been attempted and included in the plan of care, except in an emergency . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676214 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 676214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store and prepare food in a sanitary manner, in that: 1) Undated and unlabeled food were in the refrigerator and freezer. 2) Frozen food items were stored on the floor in the freezer. These failures could place residents who were served meals from the facility's kitchen at risk for food borne illness. The findings were: Observation during the initial tour of the kitchen on 04/18/23 at 9:20 AM revealed in the refrigerator a container with an opened undated package of [NAME] in a plastic sandwich bag and an undated package of pepperoni slices. The DS took out the package of [NAME] and pepperoni and asked the Dietary Aide to throw it out. Observation on 04/18/23 at 9:23 AM of the freezer revealed an opened box of Premium Reserve Pork with three individual wrapped pork meat packages, 2 unopened packages of different flavored popsicles and an unknown large frozen package of meat wrapped in pink plastic were on the floor of the freezer. The DS said nothing should be placed on the floor. The DS said the unknown package of meat would be thrown out. The three pork meat packages were taken out of the box and placed on the shelf along with the popsicles. In an interview on 04/18/23 at 9:27 AM the DS said all food must be labeled and dated when it is received. If any food is opened it should be stored separately and labeled and dated when opened. All staff are responsible for labeling and dating food in the refrigerator or freezer. Opened items are stored in the refrigerator for three days and then thrown out. If there is no opened date, then that food would be thrown out. The Dietary Supervisor said nothing should be placed on the floor. DS asked the Dietary Aide if she knew why the items in the freezer were placed on the floor and if she knew what type of meat that was wrapped in the pink plastic and when was it received. The Dietary Aide said she did not know what it was nor when it was received. The DS said the unknown package of meat would be thrown out. The pork meat was taken out of the box and placed on the shelf along with the popsicles. The DS said they will not use food that is not labeled or dated. DS was asked twice what the consequences of not labeling and dating food when stored in the refrigerator would be and each time the DS just said, We will not use food that is unlabeled or undated, it will be thrown out. In an interview on 04/19/23 at 10:20 AM Dietary Aide A said the food must be labeled and dated when it is stored, and the food must never be on the floor. Dietary Aide A said the [NAME] and the Dietary Supervisor are responsible for putting the foods in the refrigerator or the freezer. Everything must be off the floor and when a package is opened, the date the package was opened must be written on the package. The Dietary Aide said anything not dated must be thrown out because they don't know how long it has been in the refrigerator or freezer and if it was contaminated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676214 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 676214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 04/19/23 at 10:35 AM [NAME] B said all staff are responsible to put the food in the refrigerator or the freezer. [NAME] B said they must date and label all food items in the refrigerator or freezer. If a package is opened, they must put the date the package was opened before placing it in the refrigerator or freezer. [NAME] B said when their food order arrives, they must place all items on a cart and then they must be labeled and dated before putting them away six inches from the floor. [NAME] B said they would not use any item that was not labeled or dated. The [NAME] said they would not use it because they do not know if it was still good. In an interview on 04/19/23 at 3:43 PM the Dietary Consultant said she had not provided any in-services to the dietary staff but would do so since they had food that was unlabeled and undated in the refrigerator and food on the freezer floor. In an interview on 04/19/23 at 03:50 PM The Administrator said he and the Dietary Consultant oversee the kitchen. The Administrator said the Dietary Consultant has not physically been at the facility. The Administrator said the Dietary Consultant only does face time visits with the staff ever since the COVID-19 pandemic. The Administrator said he would call the Dietary Consultant and request she come to the facility and provide in-services to the staff and conduct an inspection and address any concerns found during the survey. Record review of facility's policy revised on 07/2014 regarding Food Receiving and Storage, revealed: Food shall be received and stored in a manner that complies with safe food handling practices. 7. All foods stored in the refrigerator or freezer shall be covered, labeled, and dated (use by date). 1) FDA (Food and Drug Administration) Food Code 2017, Preventing Contamination from the Premises 3-305.11, Food Storage, indicated: (A) Except as specified in - (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676214 If continuation sheet Page 5 of 5