Health inspection·January 30, 2026

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete said the notice should have had the OMB's information. The ADM said he was not sure if the notice provided to Resident #1 had the OMB's information. The ADM said he just followed the notice letter template. The ADM said he was not sure where the template was from, but the DON provided the template to him. In an interview on 01/30/26 at 5:25 PM, with the DON, she said the ADM asked her for the 30-day discharge notice template. The DON said she was not sure what the notice information was supposed to consist of. The DON said she did a web search for examples, obtained a template, and provided the template to the ADM. Record review of the facility's Transfer and Discharge Notice policy dated December 2016 reflected - Policy: Our facility shall provide a resident and/or the resident's representative with a 30-day written notice of an impending transfer or discharge.3. The resident and/or representative will be notified in writing of the following information: c. The location to which the resident is being transferred or discharged ;f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman. Event ID: Facility ID: 676214 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 676214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected inappropriate behaviors such as inappropriate comments, taking facility/staff items, playing music loudly, and recording with his phone. This failure could place residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #1's face sheet, dated 01/30/26, reflected the resident was a [AGE] year-old male, admitted [DATE], with diagnoses that included type 2 diabetes (high levels of sugar in blood), major depressive disorder, heart disease, end stage renal disease (kidney failure), and dependence on renal dialysis (treatment to manage kidney function). Record review of Resident #1's MDS assessment, dated 01/01/26, reflected Resident #1 had a BIMS score of 13, indicating intact cognition. Record review of Resident #1's care plan, dated 01/30/26, reflected Resident #1 had no inappropriate behaviors such as making rude/inappropriate comments, taking facility/staff items, playing music loudly, and recording with his phone. Record review of Resident #1's progress notes dated 08/29/25-01/30/26 revealed progress notes related to Resident #1's behaviors:On 10/16/25 at 11:24 AM - Resident was being inappropriate and using vulgar language with staff. Resident stated that he could see the staff's private area through her pants. Staff expressed that they felt very uncomfortable with the resident and language being used.On 12/20/25 at 2:18 PM - Staff reported that resident was seen taking furniture out of other rooms and placing them in his room. Staff educated resident on the dangers of moving furniture that could cause potential injuries.Resident #1's progress notes did not reflect other progress notes related to Resident #1's behaviors or interventions implemented to address behaviors. In an interview on 01/30/26 at 11:15 AM, with the ADON, she said Resident #1 made inappropriate comments to the staff such as talking about their bodies. The ADON said Resident #1 took belongings from the staff's lounge such as the staff's meals and took facility belongings to his room like the nurse station's chair. The ADON said they redirected Resident #1 to stop these behaviors. The ADON said Resident #1 started recording staff with his phone which she was not sure if he was allowed to do. The ADON said Resident #1 played his music loudly which did not allow others to sleep. The ADON said they verbally redirected Resident #1 to stop recording and to use his headphones when listening to music at night so residents could sleep. The ADON said she was not sure if these behaviors were care planned. The ADON said the DON updated care plans. In an interview and observation on 01/30/26 at 12:25 PM, with Resident #1, he said he was given a 30-day discharge notice by the ADM because of his behaviors. Resident #1 said he did not agree with the notice as he did not behave or do the things the facility said he was doing. Resident was not injured or in distress. In an interview with on 01/30/26 at 3:15 PM, with the DON, she said Resident #1 had inappropriate behaviors such as making rude/sarcastic comments towards the staff. The DON said other residents complained that they could not sleep because of Resident #1 playing his music loudly. The DON said most recently, Resident #1 started recording the staff and tried to catch them doing something wrong. The DON said she reviewed the residents' chart and updated the care plans as needed. The DON said Resident #1's behaviors were not care planned but should have been. The DON said the staff verbally redirected Resident #1 to stop the behaviors, but there were no other interventions implemented for the behaviors. The DON said there was no negative outcome for Resident #1. The DON said it was important for the care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676214 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 676214 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2026 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to be individualized and developed accurately so staff knew how to care for the residents. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated December 2016 reflected - Policy: 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.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes. Event ID: Facility ID: 676214 If continuation sheet Page 4 of 4