Health inspection·August 28, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 2 of 5 residents (Resident #2 and Resident #3) reviewed for resident rights. 1. The facility failed to place a privacy cover over Resident #2's catheter bag while she was in bed at 10:30 AM on 08/26/25. 2. The facility failed to place a privacy cover over Resident #3's catheter bag while she was in bed at 11:20 AM on 08/26/25. These failures could result in psychosocial harm to the residents, including feelings of shame and embarrassment and a loss of dignity. Findings included: 1. Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included unspecified protein calorie malnutrition (a state of inadequate nutrient intake), osteomyelitis (infection of the bone) of vertebra (spinal column), sacral (the triangular bone at the base of the spine), and sacrococcygeal region (the junction between the sacrum and the coccyx, or tailbone), local infection of the skin and subcutaneous tissue (tissue under the skin), dehydration, urinary tract infection, sepsis (damage to vital organs caused by an infection), pressure ulcer of sacral region, dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), and metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body). Record review of Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE] reflected BIMS scores of 0 and 1 respectively, which indicated Resident #2 had severe cognitive impairment.Record review of Resident #2's order summary report on 08/26/25 reflected an active order for Resident #2 to have a foley catheter (urinary catheter) for urinary retention (inability to empty the bladder) and for foley catheter care every shift initiated on 06/25/25.Record review of Resident #2's comprehensive care plan dated 06/25/24 reflected the focus I have a foley for urinary retention initiated on 06/25/24. Interventions listed for the focus included:- My nurse changes my catheter sterile method as ordered by my MD and as needed for infection/ occlusion initiated 06/25/25.- My nurse irrigates my foley catheter with 30ml of NS sterile method as needed for patency initiated 06/25/25.- My nurse monitors me for s/s of UTI including cloudy urine, sediment, odor to urine, dysuria, abdominal distention, pain, fever, chills, change in LOC initiated on 06/25/25.- my staff perform foley catheter care Qshift initiated 06/25/25.During an observation of Resident #2 in her room in bed at 10:30 AM on 08/26/25, Resident #2's catheter bag did not have a privacy cover over it. The privacy cover was located on the opposite side of the bed attached to the lower bed rail. An interview was attempted with Resident #2, but she was not interviewable.In an interview on 08/26/25 at 10:35 AM, Resident #2's FM stated Resident #2 had a bag that the staff put the foley drainage bag into sometimes but not all the time. 2. Record review of Resident #3's face sheet dated Page 1 of 13 676214 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/26/25 revealed an [AGE] year-old female with an initial admission date of 04/30/24 and a current admission date of 06/29/24. Pertinent diagnoses included depression (mood disorder, characterized by persistent low mood, loss of interest, and difficulty with daily activities for at least two weeks) and retention of urine (inability to empty the bladder completely). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 (severe impairment). Record review of Resident #3's comprehensive care plan dated 08/26/25 revealed the focus 6/20/25 I was noted with severe excoriation and irritation to perineal area. My [doctor] ordered to place foley catheter initiated on 06/20/25. Interventions listed for the focus included:- My nurse inserts foley catheter using sterile technique as ordered by my doctor initiated 06/23/25- My nurse monitors my urine output every shift as ordered by my doctor initiated 06/23/25.- My nurse provides foley catheter care every shift as ordered by my doctor initiated 06/23/25.- My nurses remind me on the importance of drinking water initiated 07/18/25. Record review of Resident #3's order summary revealed an active order for Foley Catheter Care every shift initiated on 06/20/25. During an observation of Resident #3 in her room in bed at 11:20 AM on 08/26/25, Resident #3's catheter bag did not have a privacy cover over it. An interview was attempted with Resident #3, but she was not interviewable. In an interview with CNA B at 9:43 AM on 08/28/25, CNA B stated residents were supposed to have privacy covers over their catheter bags. CNA B stated if she saw a catheter bag without a privacy cover, she would immediately grab a privacy cover and place it over the catheter bag. CNA B stated she did that to protect the privacy and dignity of the residents because they may otherwise feel embarrassed. In an interview with RN A at 9:51 AM on 08/28/25, RN A stated if she saw a resident with a catheter bag without the privacy cover, she would locate a privacy cover and place it over the catheter bag. RN A stated she did that to protect the privacy and dignity of the resident. RN A stated the privacy covers helped residents feel less embarrassed and ashamed of the medical care they received. In an interview with the DON at 10:08 AM on 08/28/25, the DON stated catheter bags should have privacy covers on them at all times except when a nurse was actively adjusting something with the catheter bag. The DON stated privacy covers were important to protect the resident's privacy and dignity. Record review of the undated facility policy titled Resident Rights revealed the following: Employees shall treat all residents with kindness, respect, and dignity.These rights include a resident's right to a dignified existence. 676214 Page 2 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and were knowledgeable about the resident's status, needs, strengths, and areas of decline for 1 (Resident #2) of 6 residents reviewed for assessments.The facility failed to include Resident #2's use of bed rails in both her quarterly MDS dated [DATE] and her significant change MDS assessment dated [DATE].These failures could result in residents in the facility not being provided with the necessary care or services or implementation of personalized care plans developed to address their specific needs. Findings included:Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included unspecified protein calorie malnutrition (a state of inadequate nutrient intake), osteomyelitis (infection of the bone) of vertebra (spinal column), sacral (the triangular bone at the base of the spine), and sacrococcygeal region (the junction between the sacrum and the coccyx, or tailbone), local infection of the skin and subcutaneous tissue (tissue under the skin), dehydration, urinary tract infection, sepsis (damage to vital organs caused by an infection), pressure ulcer of sacral region, dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), and metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body). Record review of Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE] reflected BIMS scores of 0 and 1 respectively, which indicated Resident #2 had severe cognitive impairment. Record review of section P of the same MDS assessments reflected, Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The code entered for both assessments was 0- Bed rails not used. Record review of Resident #2's order summary report reflected an active order for Resident #2 to have bilateral full side rails in place every shift dated 07/24/25.Record review of Resident #2's Side Rail Use Assessment Form signed by the DON and Resident #2's FM on 07/24/25 reflected in part: 10. Has the RP expressed a desire to have side rails raised while in bed for safety and/or comfort? Yes11. Has the RP requested that the side rails not be released while sleeping? Yes Recommendations: Bilateral (both sides)Observation on 08/26/25 at 9:30 AM reflected Resident #2 had full side rails in the up position on both sides of her bed while she was in bed.In an interview on 08/28/25 at 9:30 AM, Resident #2's three FMs stated they were all aware of the risks associated with bed rails, however they felt better with her having side rails because they were concerned that she would try to get out of bed and fall if no one was there to stop her. Resident #2's FMs stated she was frequently confused and forgot that she did not have the strength to get out of bed. In an interview on 08/28/25 at 12:18 PM, the ADON stated she had been doing the MDS job for about seven or eight months after the previous MDS nurse left. The ADON stated on Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE], the bed rails were not being used as a restraint, so she answered the question as no. She stated she did not code it as a physical restraint because it was for family's peace of mind. She stated the family stated they knew she was bed bound and that she did not really move, but they still wanted the rails. The ADON stated, If it was a patient that we had put rails on because they were trying to get out of bed or something, then it would be coded as a physical restraint. The ADON stated it was important to code things correctly because it was submitted to Residents Affected - Few 676214 Page 3 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CMS and that was how they figured reimbursement and quality measures. The ADON stated if the MDS was not accurate, the facility could get cited or have to repay money paid to the facility based on resident assessments. In an interview on 08/28/25 at 12:30 pm, the DON stated the newer beds the facility received, which Resident #2 was using, came with side rails on them. The side rails were not initially up on the bed, however Resident #2's family requested the side rails up all the time because they were concerned that she would try to get out of bed. The DON stated Resident #2 had minimal movement on her own and she required complete assistance for turning, repositioning, and all other things. The DON stated the family was educated about the risks of side rails and decided they wanted them anyway. The Side Rail assessment form was signed by one of the family members and the DON on 07/24/25. The DON stated side rail assessments were done quarterly. The risks of side rails included broken bones, strangulation, bruises/skin tears, falls, and even death. She stated there was not a medical rationale for the bed rails, but the family requested the bed rails for their peace of mind. The DON stated the MDS assessments were being done by the ADON, and it was important for the MDS to be coded correctly so the facility was paid correctly by CMS. Record review of the facility's Proper Use of Side Rails policy dated 2001 and revised 12/2016 reflected in part: Purpose The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms.Definition Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.)General GuidelinesI. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) 676214 Page 4 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure residents comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including the comprehensive, quarterly, and significant change assessments.The facility failed to update Resident #2's care plan to include the use of full bed rails on 07/30/25 when her quarterly MDS assessment was completed and on 08/20/25 when a significant change MDS assessment was completed.These failures could place residents in the facility at risk of not being provided with the necessary care or services or implementation of personalized care plans developed to address their specific needs. Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Her diagnoses included unspecified protein calorie malnutrition (a state of inadequate nutrient intake), osteomyelitis (infection of the bone) of vertebra (spinal column), sacral (the triangular bone at the base of the spine), and sacrococcygeal region (the junction between the sacrum and the coccyx, or tailbone), local infection of the skin and subcutaneous tissue (tissue under the skin), dehydration, urinary tract infection, sepsis (damage to vital organs caused by an infection), pressure ulcer of sacral region, dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), and metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body). Record review of Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE] reflected BIMS scores of 0 and 1 respectively, which indicated Resident #2 had severe cognitive impairment. Record review of Resident #2's order summary report reflected an active order for Resident #2 to have bilateral full side rails in place every shift dated 07/24/25.Record review of Resident #2's care plan did not reflect the use of side rails.Record review of Resident #2's Side Rail Use Assessment Form signed by the DON and Resident #2's FM on 07/24/25 reflected in part: 10. Has the RP expressed a desire to have side rails raised while in bed for safety and/or comfort? Yes11. Has the RP requested that the side rails not be released while sleeping? Yes Recommendations: Bilateral (both sides)Observation on 08/26/25 at 9:30 AM reflected Resident #2 had full side rails in the up position on both sides of her bed while she was in bed. In an interview on 08/28/25 at 9:30 AM, Resident #2's three FMs stated they were all aware of the risks associated with bed rails, however they felt better with her having side rails because they were concerned that she would try to get out of bed and fall if no one was there to stop her. Resident #2's FMs stated she was frequently confused and forgot that she did not have the strength to get out of bed.In an interview on 08/28/25 at 12:42 PM, the DON stated care plans were completed by the DON, the ADON, and RN A. She stated Resident #2's care plan review was started on 07/09/25 so it would have been added by the end of the review period, which was 10/09/25. The DON stated it was important for the care plan to be accurate because it was her plan of care, an overall view of what was going on with the resident and if the care plan was not accurate it would not show accurate information. The DON stated the care plan was updated every three months, but if there were any new orders or issues, they were put into the care plan right away. The DON stated Resident #2's side rails were not care planned because it was overlooked. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated 2001 and revised 12/2016 reflected in part: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and 676214 Page 5 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implementationl. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The care planning process will:b. Include an assessment of the resident's strengths and needs.8. The comprehensive, person-centered care plan will:g. Incorporate identified problem areas.h. Incorporate risk factors associated with identified problems.j. Reflect the resident's expressed wishes regarding care and treatment goals.k. Reflect treatment goals, timetables and objectives in measurable outcomes.12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.14. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the resident's condition;b. When the desired outcome is not met;c. When the resident has been readmitted to the facility from a hospital stay; andd. At least quarterly, in conjunction with the required quarterly MDS assessment. Record review of the facility's Proper Use of Side Rails policy dated 2001 and revised 12/2016 reflected in part: 4. The use of side rails as an assistive device will be addressed in the resident care plan. 676214 Page 6 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #2) of three residents reviewed for urinary catheters. Resident #2's urinary catheter tubing did not have an unobstructed urine flow, and the collection bag was not below Resident #2's bladder at all times.This failure places residents with urinary catheters at risk for urinary tract infections. Record review of Resident #2's admission record reflected a [AGE] year-old female resident initially admitted to the facility on [DATE] with most recent admission on [DATE]. Pertinent diagnoses included unspecified protein calorie malnutrition (a state of inadequate nutrient intake), urinary tract infection, osteomyelitis (infection of the bone) of vertebra (spinal column), sacral (the triangular bone at the base of the spine), and sacrococcygeal region (the junction between the sacrum and the coccyx, or tailbone), local infection of the skin and subcutaneous tissue (tissue under the skin), dehydration, sepsis (damage to vital organs caused by an infection), pressure ulcer of sacral region, dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities), and metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body).Record review of Resident #2's quarterly MDS assessment dated [DATE] and significant change MDS assessment dated [DATE] reflected BIMS scores of 0 and 1 respectively, which indicated Resident #2 had severe cognitive impairment.Record review of Resident #2's order summary report on 08/26/25 reflected an active order for Resident #2 to have a foley catheter (urinary catheter) for urinary retention (inability to empty the bladder) and for foley catheter care every shift initiated on 06/25/25.Record review of Resident #2's comprehensive care plan dated 06/25/24 reflected the focus I have a foley for urinary retention initiated on 06/25/24. Interventions listed for the focus included:- My nurse changes my catheter sterile method as ordered by my MD and as needed for infection/ occlusion initiated 06/25/25.- My nurse irrigates my foley catheter with 30ml of NS sterile method as needed for patency initiated 06/25/25.- My nurse monitors me for s/s of UTI including cloudy urine, sediment, odor to urine, dysuria, abdominal distention, pain, fever, chills, change in LOC initiated on 06/25/25.- my staff perform foley catheter care Qshift initiated 06/25/25.During an observation of Resident #2 in her room in bed at 10:30 AM on 08/26/25, Resident #2's urinary catheter drainage bag was attached to the right side of her bed on the rail just below the mattress. The catheter drainage bag was not below Resident #2's bladder.During an observation of Resident #2 in her room in bed at 9:23 AM on 08/28/25, Resident #2's urinary catheter drainage bag was attached to the right side of her bed on the rail just below the mattress. The urinary catheter tubing was routed up over the top of the side rail and the drainage bag was not below the level of her bladder. There was urine backed up in the tubing that was unable to drain into the bag, as it was not able to travel against gravity to drain.An interview was attempted with Resident #2, but she was not interviewable.In an interview on 08/28/25 at 9:43 AM, CNA B stated the catheter tubing and drainage bag were supposed to be below the bladder and off the floor. CNA B stated if she saw urinary catheter tubing that was not able to flow freely she would immediately wash her hands, put her gloves on, then fix the tubing so it was below the bladder.In an interview on 08/28/25 at 9:51 AM, RN A stated the catheter tubing an drainage bag were supposed to be below the bladder and on the opposite side of the bed from the door and off the floor. RN A stated if she saw the tubing was above the bladder, she would reposition it so it was below the bladder but still not touching the floor. RN A 676214 Page 7 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she would reposition it because it caused the urine to be retained in the bladder, and it needed to flow to minimize the risk of infection, pain, and bladder spasms. Record review of the facility's undated Foley Catheter Care Policy reflected in part: PurposeTo ensure safe and effective management of indwelling urinary catheters and to reduce the risk of catheter-associated urinary tract infections (CAUTIs).Policy StatementAll staff involved in catheter care must follow aseptic technique, adhere to infection control standards, and provide routine assessment and hygiene to minimize complications.2. MaintenanceKeep catheter tubing free from kinks and secured to patient's thigh.Position drainage bag below bladder level, off the floor. 676214 Page 8 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #14) reviewed for respiratory care. The facility failed to ensure Resident #14's oxygen tubing was stored off the floor and in a bag when not in use at 11:09 AM on 08/26/25. This failure placed residents at an increased risk of infection leading to a decline in health.The findings included:Record review of Resident #14's face sheet dated 08/26/25 revealed an [AGE] year-old female with an initial admission date of 03/26/02 and a current admission date of 07/29/13. Pertinent diagnoses included vascular dementia (cognitive decline caused by damage to the blood vessels in the brain) and chronic obstructive pulmonary disease (chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed a BIMS of 5 (severe impairment). Further review revealed Resident #14 received oxygen therapy in the last 14 days while a resident at the facility. Record review of Resident #14's comprehensive care plan dated 08/26/25 revealed the focus I have a diagnosis of COPD initiated on 05/01/24. Interventions listed for the focus included:- I have follow ups with my pulmonologist as appropriate initiated on 05/01/24.- I receive oxygen as ordered by my doctor initiated on 05/01/24 and revised on 05/01/25. Record review of Resident #14's order summary revealed an active order for 02 @ 3L NC every shift for SOB initiated on 05/06/25. During an observation of Resident #14's room at 11:09 AM on 08/26/25, Resident #14 was not in the room, oxygen tubing and nasal canula were on the floor beside the bed not in a bag. In an interview with CNA B at 9:43 AM on 08/28/25 CNA B stated if she saw a nasal canula with oxygen tubing on the floor she would inform the nurse and then discard of the tubing. CNA B stated she would discard the tubing because after it was on the floor it became contaminated. CNA B stated if a resident used a contaminated nasal canula for oxygen they would be exposed to more germs and bacteria. In an interview with RN A at 9:51 AM on 08/28/25, RN A stated if she saw oxygen tubing on the ground, she would put it in the trash and get new tubing for the resident. RN A stated she would discard of the tubing due to an increased risk of infection if the resident used dirty oxygen tubing. In an interview with the DON at 10:08 AM on 08/28/25, the DON stated oxygen tubing should not be left on the floor. The DON stated the tubing should have been in a bag because it was not in use at the time it was on the floor. The DON stated if a staff member came across oxygen tubing on the floor, they should discard it and get new tubing. The DON stated once the tubing was on the floor it became contaminated and increased the risk of infections for residents if they continued to use the same tubing. Record review of the facility policy titled Oxygen Administration dated 07/15 revealed the following policy: .Check the tubing connected to the oxygen cylinder to assure that it is free of kinks.a. Date and initial tubing.b. Change equipment every (7) seven days.c. Store equipment in a bag when not in use.d. Change or clean O2 filter weekly. Residents Affected - Few 676214 Page 9 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

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. Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1unit refrigerators reviewed for storage, preparation and sanitation. -The facility failed to ensure food items in the facility kitchen refrigerator were labeled and dated. -These failures could place residents at risk for complications from food contamination. Findings included: Observations during the initial tour of the kitchen on 08/26/25 at 8:00 AM, revealed one bag with four green peppers had black mold and did not have a use by date. In an interview with DA H on 08/26/25 at 9:32 AM, she said all kitchen staff was responsible for cleaning the refrigerator and made sure that all food was labeled, had not expired and had a use by date. DA H stated the fridge was cleaned and all expired food was thrown out daily. DA H could not explain why the green peppers did not have a date of when they were placed in refrigerator. In an interview with DA I on 08/26/25 at 9:46 AM, she stated she could not recall when the green peppers were placed in the refrigerator but knew that all items put in the refrigerator was to have a use by date. DA I stated the staff throws away all expired food daily and cleans refrigerator weekly. DA I stated last week she did not have a need for the green peppers for cooking, so she had not been in the refrigerator drawer where they were stored. In an interview with the DM on 08/26/25 at 9:43 AM, stated she and the staff clean out the refrigerator daily and the green peppers looked ok on the top but when you lifted the bag the bottom of the green peppers were rotten. The DM said they had not been used for cooking in a while and that could be why the green peppers were not noticed with no use by date and had spoiled. The DM stated she did not know why they did not have a date on them of when the green peppers were put in the refrigerator as all other items had a date. The DM stated she will do retraining on dating items and making sure they are all covered and throwing out expired foods for all forms of storage. Record review of the facility's policy dated 07/2014, titled, Food Receiving and Storing revealed Food Services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) FDA Food Code 2022 Ch. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. to (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETYFOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 676214 Page 10 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #3 and Resident #27) of 5 residents reviewed for infection control.1. The DON, LVN C, and CNA D did not wash their hands before and after performing wound care for Resident #3.2. The DON did not pat dry wound while performing wound care for Resident #3.3. LVN C and CNA D did not wash their hands after performing incontinent care for Resident #3.4. The facility failed to ensure CNA D did not grab Resident #27's cup and bowl by the rim with her bare hands, contaminating the tops of the rims, during the lunch meal serving process. These failures could place residents at risk for infection through cross contamination of pathogens and infectious diseases. Residents Affected - Few 2. and 3. Record review of Resident #3's admission record reflected an [AGE] year-old female initially admitted to the facility on [DATE] with most recent admission on [DATE]. Pertinent diagnoses included infection of amputation stump, left lower extremity, pressure ulcer of unspecified part of back, pressure ulcer of sacral region- unstageable, pressure ulcer of right ankle- unstageable, open wound of right foot, depression (mood disorder, characterized by persistent low mood, loss of interest, and difficulty with daily activities for at least two weeks) and retention of urine (inability to empty the bladder completely). Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. Record review of Resident #3's care plan dated 05/01/24 reflected the focus 06/17/25 I returned from hospital stay with a stage 3 sacral pressure wound. 08/04/25 My sacral wound is now unstageable, initiated on 06/17/25, revised on 08/26/25, 08/04/25 I returned back from the hospital with a dx of sepsis. My sacral ulcer is positive for MRSA and E. coli. 08/24/25 My MD ordered to begin Augmentin 500mg BID for 10 days for sacral wound infection, initiated on 08/05/25, revised on 08/26/25, and I have a stage 2 wound to my right middle back, initiated on 08/24/25. Interventions for these focuses included: - My nurse monitors my wound for s/s of infection such as fever, heat to site, swelling, redness, purulent drainage, chills, tachycardia (no initiated date). - My nurse performs wound care as ordered by my MD initiated 06/17/25. Record review of Resident #3's order summary report reflected an active order for Resident #3's wound care on her sacrum that read, Unstageable sacral ulcer: cleanse with wound cleanser or wound solution, pat dry with gauze, apply calcium alginate, pack with dry gauze, apply skin prep to peri wound, let dry, then cover with dry dressing daily and as needed for loose/soiled dressing one time a day, dated 08/28/25. Observation of wound care for Resident #3's sacral wound on 08/28/25 at 11:40 AM reflected the DON, LVN C, and CNA D used hand sanitizer then donned PPE before entering Resident #3's room. The DON, LVN C, and CNA D did not wash their hands prior to initiating wound care on Resident #3. The DON did not pat dry as stated in physician orders after cleansing Resident #3's unstageable pressure ulcer to her sacrum. The DON, LVN C and CNA D did not wash their hands after performing (or assisting with) 676214 Page 11 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound care for Resident #3. LVN C and CNA D did not wash their hands after performing incontinent care for Resident #3. In an interview on 08/28/25 at 12:07 PM, the DON stated they had all sanitized before putting on PPE and she thought that was acceptable. She stated it was important to wash hands before doing wound care for infection control. The DON stated scrub time with hand washing was at least 20 second and it was important to wash hands before exiting the room after wound care or incontinent care to prevent the spread of infection. She stated it was important to follow the physician orders and pat the wound dry to decrease the chance if contamination of the wound after it was cleaned. The DON stated the last in-service on infection control and hand washing was on 08/15/25 and they were usually done every three months and as needed. In an interview on 08/28/25 at 12:10 PM, LVN C stated she did not wash her hands before assisting with wound care because she sanitized her hands before putting on her PPE. LVN C stated it was important to wash hands to prevent the spread of infection between residents. LVN C stated she did not wash her hands when she exited the room because she did not touch the resident's wound and her hands were not visibly soiled, so she used hand sanitizer. In an interview on 08/28/25 at 12:15 PM, CNA D stated handwashing was to be done if hands were visibly soiled, otherwise hand sanitizer was appropriate to use. CNA D stated it was important to cleanse hands between residents to ensure she did not spread infection to other residents. In an interview on 08/28/25 at 1:06 PM, the ADON stated hand washing was important to prevent the spread of germs. Hand washing was done anytime the hands were visibly soiled, before and after wound care was done, and when contact was made with indwelling devices. The ADON stated if hands were not washed it could cause cross contamination. Record review of the facility's Infection Control In-Service dated 08/15/25 reflected an Infection Control Quiz with the following: 1. The most important way to prevent infection is: [The correct answer was b) Hand hygiene] a) Wearing gloves b) Hand hygiene c) Wearing a mask 2. When must you wash your hands: [The correct answer was f) All of the above] a) Before/after resident contact b) After glove removal c) Before eating d) After using restroom e) After coughing/sneezing 676214 Page 12 of 13 676214 08/28/2025 Falcon Lake Nursing Home, LLC 200 Carla St Zapata, TX 78076

F 0880 f) All of the above Level of Harm - Minimal harm or potential for actual harm 4. Record review of Resident #27's face sheet revealed a [AGE] year-old female initially admitted on [DATE], and diagnosis of Paranoid Schizophrenia (Persistent delusions and hallucinations), Dementia (A group of thinking and social symptoms that interfere with daily functioning), Anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Residents Affected - Few Record review of Resident #27's MDS Quarterly Assessment date 05/28/2025 revealed Resident #27 had a BIMS Score of 08 -moderate cognitive impairment. The assessment indicated Resident #27 needed some assistance with all ADLs. During a lunch dining observation on 05/28/25 at 12:30, PM CNA D was observed touching the rims of Resident # 27's cups and bowls with bare hands during the meal serving process. In an interview on 08/26/25 at 12:50 PM with Resident #27, she stated she had never felt ill after eating. Resident #27 also stated she had not experienced any gas, nausea, diarrhea from the food served at the facility. Resident #27 stated she had not noticed her bowl and cup were touched at the rim by CNA D. In an interview on 08/26/25 at 1:07 PM, CNA D stated training regarding how to serve the meal and how to properly handle the items while serving meals to residents approximately 3 months ago. CNA D stated she should have grabbed Resident's #27's bowls on the outside instead of grabbing the items from the rim. CNA D stated she knew how to properly serve drinks or bowls but was nervous and stated grabbing the rim of the resident's cups and bowls could lead to germs and cross contamination. In an interview on 08/26/25 at 1:14 PM, ADON stated she received training for infection control and how not to touch rims of the cups. The cups should be grabbed on the side and offered to the resident as the rim of the cups should not be touched by staff bare hands as it could lead to cross contamination when the resident goes to drink out of it. In an interview on 08/26/25 at 1:32 PM, the DM stated the ADON, and the DON were responsible for infection control and teaching the staff about proper hand sanitation and serving the resident's food correctly. Record review of the facility policy titled; Handwashing/Hand Hygiene revised August 2015 revealed in the Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Procedure Washing Hands 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds or longer under a moderate stream of running water at a comfortable temperature. 676214 Page 13 of 13