Inspection·August 4, 2023

F 0636 way to make sure they are getting the care they need in the new facility according to their conditions. Level of Harm - Minimal harm or potential for actual harm Record review of facility policy Comprehensive care Plans, implemented 2/10/21, read, in part: .care planning process will include an assessment of the resident's strengths and needs, and will oncorporate resident's personal and cultural preferences .will describe discharge plans, as appropriate . Residents Affected - Few Record review of facility policy Transfer and Discharge, reviewed 2/20/2020, read, in part: .for community discharge, a discharge summary and plan of care should be prepared for the resident .for transfer to another provider, the following information must be provided to the receiving provider: .all special instructions or precautions for ongoing care, comprehensive care plan goals, copy of resident's discharge summary to ensure a safe and effective transition of care . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 2 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to coordinate assessments with the (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents (Resident #34) reviewed for PASARR. The facility failed to update the PASARR Level 1 forms for Resident #34 after a new diagnosis of mental illness after admission. This failure could place residents requiring PASARR services at risk of not having their needs assessed and met by the facility. Findings included: Record review of Resident #34's undated face sheet, revealed a [AGE] year-old male readmitted on [DATE] with diagnoses of pneumonia (infection of the lung), acute respiratory failure with hypoxia (impairment of gas exchange between lungs and blood causing decreased oxygen), bipolar disorder (unusual shifts in person's mood, energy, activity levels, and concentration), cognitive communication deficit (difficulty thinking and using language), major depressive disorder (extreme sadness and tearfulness), anxiety disorder, and cardiac arrhythmia (abnormal rhythm of the heart). Record review of Resident #34's Annual MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated normal cognition. For the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, no was answered. The Level II Preadmission Screening and Resident Review Conditions were left blank. According to the resident mood interview, Resident #34 had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble falling or staying asleep, or slept too much, felt tired or had little energy, and felt bad about himself, several days over the previous 2 weeks. The MDS also revealed Resident #34 took antianxiety, and antidepressant medications. Record review of Resident #34's care plan, revised 3/30/22, revealed a focus Resident has a moderate cognitive impairment r/t anxiety, depression and bipolar disorder and is at risk for a further decline in cognitive and functional abilities. There was also a focus Resident has a actual psychosocial well-being problem r/t ineffective coping and having hx of a plan to commit suicide. Resident will identify 3 coping mechanisms to help manage symptoms of depression by the review date. Resident has a mood problem r/t disease process: bipolar and anxiety disorder. Resident will have improved mood state aeb happier, calmer appearance, and less than 3 episodes of depression, anxiety, or sadness by the review date. The care plan revealed a focus of Resident is taking psychotropic, antianxiety and antidepressant medications related to depression, anxiety, and bipolar disorders and is at risk for experiencing the adverse side effects of psychotropic medications. Record review of Resident #34's medical record revealed a PASRR Level 1 Screening performed on 7/21/2020, that revealed he had no evidence of mental illness, intellectual disability, or developmental disability prior to admitting to the facility on 6/26/20. A new Level 1 Screening was not performed after diagnosed, with mental illness in the facility. Record review of Resident #34's medical record revealed an order for Sertraline HCl 100mg 1 PO QAM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 3 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0644 for depression, ordered on 6/17/22 by Dr. S. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #34's medical record revealed a consent for an antipsychotic (Seroquel) dated 8/2/22 by PA T, to treat his bipolar. Residents Affected - Few Record review of Resident #34's medical record revealed a Diagnostic Assessment performed by Dr. A on 1/12/23, that revealed the resident had major depressive disorder with psychotic symptoms and bipolar disorder. Dr. A was treating Resident #34 with CBT. Record review of Resident #34's medical record revealed a Psychiatric Initial Assessment on 1/26/23 by Dr. K. Per Dr. K, resident had bipolar disorder and generalized anxiety disorder, and was being treated with Seroquel, Depakote, Zoloft, and Clonazepam. Record review of Resident #34's medical record revealed an order for Buspirone HCl 5mg 1 PO TID for anxiety, ordered on 8/2/23 by Dr. S. There was also an order for Clonazepam 0.5mg 1 PO BID for anxiety, ordered on 5/29/23 by Dr. S. Record review of Resident #34's August 2023 MAR revealed on 8/3/23 he took Clonazepam 0.5mg for anxiety, Sertraline HCl 100mg for depression, and Buspirone HCl 5mg TID, for anxiety. In an interview with the MDS Coordinator on 8/3/23 at 11:05am she stated, she did a quarterly review of the charts and diagnoses. She stated she had been the MDS Coordinator for 2 years. The MDS Coordinator stated she had just submitted the 1012 form for Resident #34's PASRR re-evaluation yesterday (8/2/23). She stated she did not know why it was not done and said nothing would affect the resident if it was not done. In an interview on 08/04/2023 at 10:45am with the ADM, she stated failure to identify mental illness and make necessary referrals for PASARR 2 (evaluation) could cause a delay in a resident receiving care or receiving services they could be eligible for. She said that her expectation was for PASARR level 1 screens to be completed accurately and for the necessary follow up to happen if a resident gets a new mental diagnosis during admission. The ADM said she did not have a policy specific to only PASSAR, but she was able to provide a Behavioral Health Services Policy. Record review of Behavioral Health Services Policy (11/30/2022) revealed the following: 6. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental psychosocial status and providing person-centered care. This process includes, but is not limited to: a. PASARR screening b. Obtaining history from medical records, the resident, and as appropriate the resident's family and friends regarding mental, psychosocial, and medical health. Resident #6 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 4 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0644 PASARR Level of Harm - Minimal harm or potential for actual harm 08/03/23 10:25 AM MDS Nurse [NAME] submitted 1012 for resident on 8/2/23. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 5 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities 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 the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident # 6) reviewed for PASRR assessments. Residents Affected - Few The facility failed to ensure Resident # 6 who had a diagnosis of bipolar disorder had an accurate PASARR level I assessment or received a PASARR Level II assessment or evaluation. This failure could affect residents and place all residents who admitted with a serious mental illness at risk of not receiving needed care and services to meet their individual needs. Findings included: Record review of Resident # 6's face sheet revealed she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including: bipolar disorder unspecified (a mental health disorder associated with episodes of extreme mood swings ranging from depressive lows to manic highs), anxiety disorder (a mental health disorder characterized by feelings of worry and or fear and the inability to set aside those feelings, and major depressive disorder(an illness characterized by persistent sadness and a loss of interest in activities and an inability to carry out daily activities). She did not have a diagnosis of dementia. Record review of Resident # 6's Annual MDS dated [DATE] revealed she had a BIMS score of 15 out of 15 indicating he was cognitively intact. Section I Active Diagnoses revealed she was coded as having an active diagnosis of bipolar disorder, anxiety, and depression. She was coded under Section N for Medications as having used or Antidepressant medications for 7 days. Record review of Resident # 6's PASRR level 1 screening dated 11/16/2020 revealed her PASARR screening was documented No for the question C0100. Mental Illness, Is there evidence or an indicator this is an individual that has a Mental Illness? Record review of Resident #6's care plan dated 06/06/2023 revealed she was taking psychotropic medication (medication that affects mental state) related to depression. Observation and interview on 08/01/2023 at 10:00 am of Resident #6 who was sitting up in bed watching television. She appeared relaxed and was in no distress at the time. She had no concerns regarding her care at the time. Interview on 08/03/2023 11:06am with LVN T (MDS Coordinator), she said Resident #6 does have a diagnosis of bipolar and depression. She said that Resident #6's PASARR level 1 was completed by a previous SW no longer with the facility. LVN T did not know why the question about whether there was evidence of mental illness was marked No on Resident #6's PASARR screen. LVN T said that she was not the MDS nurse when these evaluations were completed. LVN T said that she has been the MDS nurse for 2 years and that she should review diagnoses quarterly to see if a new assessment was needed. She said she missed this mistake. LVN T said she did not know she was supposed to submit form 1012 for Resident #6. She said when PASARR was negative on pre-screening but you see the resident may have depression or something, 1012 form should be submitted in order to have the resident further evaluated for mental illness. LVN T said failure to reassess in a timely manner has no impact to resident because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 6 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0645 the residents still have access to psychiatry services. Level of Harm - Minimal harm or potential for actual harm Interview on 08/04/2023 at 10:45am with the ADM, she said her expectations are for PASARR Level 1 to be completed prior to admission but they are having trouble with getting those. The PASARR level 1 ideally should be here at the facility before the resident. If they do not get a PASARR level 1 screen in a timely manner, then the facility does their best to work with the family and resident to complete it. She said she along with the MDS nurse, DON, and ADON did not know that if a resident had a negative screen but still had indicators of mental illness, they should complete a 1012. Failure to identify mental illness and make necessary referrals for PASARR 2 (evaluation) could cause a delay in a resident receiving care or receiving services they could be eligible for. The ADM said she did not have a policy specific to only PASSAR, but she was able to provide Behavioral Health Services Policy. Residents Affected - Few Record review of Behavioral Health Services Policy (11/30/2022) revealed the following: 6. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental psychosocial status and providing person-centered care. This process includes, but is not limited to: a. PASARR screening b. Obtaining history from medical records, the resident, and as appropriate the resident's family and friends regarding mental, psychosocial, and emotional health. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 7 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan was not developed within 48 hours of a resident's admission for 1 of 7 residents (Resident #69) reviewed for baseline care plan. Resident #69 did not have a baseline care plan. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care. Findings included: Record review of Resident #69's face sheet revealed admission to the facility on [DATE] and admitting diagnoses including: metabolic encephalopathy (dysfunction in the brain caused by chemical imbalance in the blood), heart failure (impaired ability of the heart to pump blood through body), cardiac arrest (temporary stopping of the heart), alcoholic cirrhosis of liver (scarring of the liver caused by excessive, prolonged alcohol consumption), stage 4 chronic kidney disease (last stage before kidney failure), acute respiratory failure (impaired ability to breathe). Record review of Resident #69's history and physical dated 06/03/2023 revealed an [AGE] year-old male evaluated for admission with management of heart attack (impaired blood flow to a portion of the heart), septic shock (severe response from immune system to an infection), new dialysis (kidney replacement therapy), heart failure, and cocaine/alcohol/tobacco use. Prior to admission, Resident #69 was placed on alcohol protocol and monitored for withdrawal from cocaine and alcohol use. Interview on 08/03/2023 at 1:30pm LVN T stated the facility unable to provide because a care plan because it was not competed. Interview on 08/03/2023 at 1:45pm RN J said the baseline care plan should be completed within 72 hours. She said it was important because it determined plan of care and also informed the resident and RP of what care was going to be provided. RN J stated failure to complete a baseline care plan can be harmful because there will not be a clear plan to communicate or determine what care a resident should have. RN J was unable to say why this resident did not have a care plan. Interview on 08/03/2023 at 2:50pm LVN T said the IDT team (MDS nurse, DON, ADON, SW, Dietary) comes up with a care plan and is responsible for updating the care plan. IDT meets daily, all work on their respective sections. They are currently going through care plans and correcting them. Care plans are behind because there are a lot of new staff, and they are trying to catch up and do the care plans properly. If anything is wrong or missing, any of the IDT team members can update it. LVN T was unable to say why Resident #69 did not have a care plan. Interview on 08/03/2023 at 3:33pm the ADM, stated nurses are responsible for completing the baseline care plan within 48 hours. She said the baseline care plan consists of eating, what resident's goals are, where they came from, current health needs, where they want to go. Failure to complete a baseline care plan can delay a resident's care or prevent the resident from getting appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 8 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0655 Level of Harm - Minimal harm or potential for actual harm treatment in a timely manner. The ADM said she does not know why Resident #69's baseline care plan was not completed, but it should have been completed within the first 48 hours of the resident being at the facility regardless of how long he was staying. Record review of the Baseline Care Plan Policy (last review 7/1/2023) revealed the following: Residents Affected - Some 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders ii. Physician orders iii. Dietary orders iv. Therapy services v. Social services vi. PASSAR recommendation, if applicable 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 9 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 record review and interview, the facility failed to develop a comprehensive resident centered care plan for each resident consistent with resident rights for 1 of 2 discharged residents reviewed for discharge care plan (Residene #67). ---there was no care plan developed for discharge for Resident #67 This failure could place residents at risk of incorrect or incomplete information regarding discharged residents, and disruption of continuity of care findings include: Resident # 67 Record review of Resident # 67's face sheet revealed an [AGE] year-old female with re-admission date of 4/18/23 and diagnoses including Diabetes, metabolic encephalopathy (a chemical imbalance in the brain), COPD (chronic obstructive pulmonary disease caused by constriction of airways), dementia (progressive or persistent loss of intellectual functioning), depression, hypertension (high blood pressure), chronic kidney disease (failure of kidneys to filter waste), osteoarthritis (degeneration of joint cartilage and bone). Date of discharge 5/9/23- to other nursing home. Record review of Resident # 67's care plan revealed no care plan for discharge planning or potential for discharge. Record review of Resident # 67's most recent quarterly MDS revealed there was no Discharge MDS. Record review of progress note dated 5/9/2023 revealed, in part: resident transported via EMS from facility accompanied by 1 EMS tech .report called to receiving facility, medications, face sheet, order summary, H & P given to EMS tech to give to receiving nurse . In an interview with MDS nurse on 8/3/23 at 2pm she said it is a team effort, and all staff work on the care plans, with input from DON, ADON, Social Worker, Dietary, and the IDT team meets to discuss care plans appropriate for a resident. She said there are a lot of new staff, and care plans were not complete, so they are trying to update the care plans. She said Quality Monitors were here last week and identified care plans as an issue and gave them a Performance Improvement Plan for care plans (dated 7/28/23). She said they were planning on correcting the care plans as soon as possible. In an interview with the DON on 8/3/23 at 3:10 pm, she said care plans needed to be accurate so residents would get the proper care, and if they were discharged , the care plan would let the new facility know the resident's needs. She said she knew the care plans were an issue after the Quality monitors were here, and they are working on getting them updated and corrected. Record review of facility policy Comprehensive care Plans, implemented 2/10/21, read, in part: .care planning process will include an assessment of the resident's strengths and needs, and will oncorporate resident's personal and cultural preferences .will describe discharge plans, as appropriate . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 10 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 Record review of facility policy Transfer and Discharge, reviewed 2/20/2020, revealed, in part: .the comprehensive person-centered care plan shall cotain resident's goals for admission and desired outcomes and shall be in alignment with the discharge . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 11 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary team after each assessment for 7 of 18 residents reviewed for care plan accuracy (Residents #3, #10, #25, #34, #65, #62, #66). --Residents #3, #10, #25, #62's care plans did not contain level of care required for ADL assistance ---Resident #25 did not have a care plan for feeding tube or therapeutic diet --Resident #34 did not have a care plan for PT/OT --Resident #65 did not have a care plan for IV antibiotics, or midline access for IV antibiotics These failures placed residents at risk of not having their individual needs identified and addressed. Findings include: Record review of Performance Improvement Plan from QA&A for care plans revealed date started 7/28/23. Record review revealed care plans for the 7 sampled residents below had not been reviewed or revised. Resident #10 Record review of Resident #10's face sheet revealed an [AGE] year-old male with admission date of 11/4/22 and diagnoses including Osteomyelitis (infection of bone), hypertension (high blood pressure), Diabetes (body's inability to process glucose), dementia (progressive loss of intellectual functioning), peripheral vascular disease (reduced blood flow to extremities). Record review of Resident #10's quarterly MDS dated [DATE] revealed a BIMs score of 7, indicating severely impaired cognitive ability, and difficulty focusing attention, easily distractable and difficulty keeping up with what is being said. Functional ability was coded as extensive staff assistance required for dressing, hygiene, bathing, toileting. Record review on 8/2/23 of Resident #10's ADL care plan dated 7/15/23 revealed: Resident has ADL selfcare Performance deficit and is at risk for not having their needs met in a timely manner . Interventions for bed mobility, transfers, toileting, ambulation, dressing, personal hygiene, and bathing did not indicate level of assistance or number of staff required to complete the task. Resident #62 Record review of Resident # 62's face sheet revealed a [AGE] year-old male with admission date of 5/15/23 and diagnoses including Paraplegia (paralysis of legs and lower body), bipolar disorder (mental health condition causing extreme mood swings), hypotension (low blood pressure), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord, or nerve damage). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 12 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview of Resident #62 on 8/2/23 at 10:10am revealed he was in bed, clean linens on bed, breakfast tray on the bedside table. In an interview at that time, he said he came here from another facility in the area, he had strokes at home and couldn't take care of himself anymore, so was moved to another nursing home and now he is here. He said he is paralyzed from the waist down from the strokes and he needs someone to help him, like with changing brief since he does not know when it needs to be changed. He said he can feel tingling in his legs so hopes that is a good sign. He said the food is ok. Record review of Resident #62's admission MDS dated [DATE] revealed a BIMs score of 12, indicating modified independence in cognitive skills, ability to understand others and be understood, incontinent of bowel and bladder, and extensive assistance of 1 staff required for dressing, extensive assistance of 2 staff for hygiene, and total assistance of 2 staff for transfer, toileting, and bathing. Record review on 8/2/23 of Resident #62's ADL care plan, initiated 6/8/23, revision on 7/11/23, revealed: Resident has an ADL self-care Performance Deficit and is at risk for not having their needs met in a timely manner . Interventions for ADL's revealed bed mobility, transfers, eating, toileting, ambulation, dressing, personal hygiene, and bathing did not have interventions to indicate level of assistance or staff required to complete the task. 1. Record review of Resident #25's undated face sheet revealed a [AGE] year-old female readmitted on [DATE] with diagnoses of metabolic encephalopathy (problem with the brain caused by a chemical imbalance in the blood), Type 1 Diabetes Mellitus (pancreas produces little to no insulin), acute respiratory failure with hypoxia (impairment of gas exchange between lungs and blood causing decreased oxygen), bipolar disorder (unusual shifts in person's mood, energy, activity levels, and concentration), heart failure (heart does not pump as well as it should), and Type 2 Diabetes Mellitus (body does not produce enough insulin or body resists it). Record review of Resident #25's Comprehensive MDS dated [DATE], revealed a BIMS of 12 out of 15, which indicated normal cognition. The resident required extensive assistance with personal hygiene, eating, dressing, and bed mobility. She was bedbound and totally dependent with transfers, toilet use, and bathing. Resident #25 had impairment with both lower extremities. She was always incontinent of bowel and bladder. According to the MDS, Resident #25 had a feeding tube and was on a mechanically altered diet. Record review of Resident #25's care plan, revised 7/19/23, revealed no focus for feeding tube or formula, carb control no added salt diet, or ADLs. Record review of Resident #25's medical record on 8/3/23 revealed an order for carb controlled, no added salt diet, regular texture, thin liquids ordered on 7/18/23. There was also an order for Glucerna 1.5, Bolus 250ml after each meal via PEG tube if resident eats less than 50% of meal, as needed ordered on 6/5/23 by Dr. G. Also, Glucerna 1.5, Bolus 250ml at HS via PEG tube, Give HS snack after bolus at bedtime for feeding ordered on 6/5/23 by Dr. G. The medical record also showed an order for PEG tube site: Cleanse area with NS, pat dry, apply TAO and drain sponge daily on 10-6 shift, ordered on 6/9/23 by Dr. G. In an observation on 8/3/23 at 1:15pm resident was observed sleeping on her side. PEG site was not visualized, but a feeding pump was next to the bed. 2. Record review of Resident #34's undated face sheet, revealed a [AGE] year-old male readmitted on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 13 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0657 Level of Harm - Minimal harm or potential for actual harm [DATE] with diagnoses of pneumonia (infection of the lung), acute respiratory failure with hypoxia (impairment of gas exchange between lungs and blood causing decreased oxygen), bipolar disorder (unusual shifts in person's mood, energy, activity levels, and concentration), cognitive communication deficit (difficulty thinking and using language), major depressive disorder (extreme sadness and tearfulness), anxiety disorder, and cardiac arrhythmia (abnormal rhythm of the heart). Residents Affected - Some Record review of Resident #34's Annual MDS, dated [DATE], revealed a BIMS of 15 out of 15 which indicated normal cognition. The resident used a wheelchair and required extensive assistance with personal hygiene, and toilet use. He had impaired lower extremities on both sides. According to the MDS, the resident had 5 days of OT in the previous 7 days. Record review of Resident #34's care plan, revised 3/30/22, revealed for his ADLs toileting required limited assistance of 1 and personal hygiene required supervision of 1. There was not a focus for PT/OT on the care plan. Record review of Resident #34's medical record on 8/2/23 revealed an order for Occupational Therapy to evaluate and provide 3 times a week treatments for 60 days for therapeutic exercise, therapeutic activity, cognition/safety. Self-care retraining and pt/caregiver education, ordered on 5/5/23. Record review of Resident #34's PT Evaluation & Plan of Treatment from 6/29/23 revealed a plan for 3xweek for 12weeks. The first PT session was on 6/29/23 and the most recent one was on 7/21/23. Observation of Resident #34 on 8/2/23 at 9:30am revealed the resident sitting in a wheelchair with impairment in his lower extremities but normal functioning of his upper extremities. 3. Record review of Resident #3's undated face sheet, revealed an [AGE] year-old female readmitted on [DATE] with diagnoses of chronic ischemic heart disease (heart disease from lack of oxygen), chronic kidney disease stage 3 (kidneys are not filtering like they should), transient ischemic attack (mini stroke), absence of leg below knee (amputation below the knee), chronic obstructive pulmonary disease (problems breathing and getting enough oxygen), Type 2 Diabetes Mellitus (body doesn't make enough insulin or body resists it), anxiety disorder, major depressive disorder, and obstructive sleep apnea (absence of breathing for moments while sleeping). Record review of Resident #3's Quarterly MDS dated [DATE], revealed a BIMS of 10 out of 15 which indicated moderately impaired cognition. The resident used a wheelchair and limb prosthesis and required extensive assistance with personal hygiene, toilet use, dressing, and bed mobility. She was totally dependent with locomotion on and off the unit, transfers, and bathing. She had a life expectancy of less than 6 months. The MDS stated the resident had no pressure ulcers. It also revealed the resident was on hospice and used oxygen. Record review of Resident #3's care plan, revised 3/30/22, revealed a BIMs of 3 instead of 10. It stated the resident had a Stage 3 pressure ulcer to her left buttock, when she did not. The care plan also failed to mention the resident was a DNR and on hospice. The care plan did not mention the resident's ability with ADLs at all. Record review of Resident #3's medical record on 8/3/23 revealed an order to admit to hospice, ordered on 5/12/21 by Dr. M. There was also a DNR order that was ordered on 6/14/22 by Dr. M. In an interview and observation on 8/3/23 at 1:20pm Resident #3 was coherent and stated she did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 14 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0657 get out of bed. She had oxygen via nasal canula on and was resting comfortably on her back. Level of Harm - Minimal harm or potential for actual harm 4. Record review of Resident #65's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE] with diagnoses of paraplegia (paralysis from waist down), cirrhosis of liver (liver damage), alcoholic hepatitis with ascites (liver damage with fluid in the stomach from excessive alcohol), and hypertension (high blood pressure). Residents Affected - Some Record review of Resident #65's MDS, dated [DATE], revealed a BIMS of 14 out of 15 which indicated normal cognition. The resident was bedbound and required extensive assistance with personal hygiene, toilet use, dressing, and bed mobility, and was totally dependent for bathing. Resident #65 had impairment to both lower extremities. Record review of Resident #65's care plan, revised 7/19/23, revealed Resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. Under the interventions, bed mobility, transfers, eating, toileting, ambulation, wheelchair, dressing, and bathing were left blank. The care plan did not address the resident's midline or the IV antibiotics he was receiving. Record review of Resident #65's medical record revealed an order to insert midline for IV antibiotics on 7/26/23, by Dr. G. There was also an order to change the transparent dressing to the Midline site every night shift, every 7 days, ordered on 7/27/23 by Dr. G. The medical record revealed an order for Ertapenem Sodium Solution 1 gm intravenously at bedtime for UTI for 10 days, ordered on 7/27/23 by Dr. G. In an interview and observation on 8/1/23 at 10:41am, Resident #65 stated he was paralyzed from his abdomen down and needed help with all his ADLs. He stated he was bedbound and had not been out of bed in 4-5wks. He stated he had a UTI, and a midline was observed on his left upper arm. 5. Record review of Resident #66's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of cerebral infarction (stroke), hypertension (high blood pressure), and Type 2 Diabetes Mellitus (body doesn't produce insulin or body is resistant). Record review of Resident #66's MDS dated [DATE], revealed a BIMS of 13 out of 15 which indicated normal cognition. The resident was bedbound and required extensive assistance with personal hygiene, toilet use, dressing, and bed mobility. He was totally dependent on transferring, locomotion on and off the unit, and with bathing. Resident #66 had impairment to both lower extremities. Record review of Resident #66's care plan, revised 7/17/23, revealed a focus Resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. For the interventions bed mobility, transfers, eating, toileting, ambulation, wheelchair, dressing, and personal hygiene were left blank on the care plan. In an interview and observation on 8/1/23 at 11:03am Resident #66 stated he had a stroke and could not move his bottom extremities. He stated he relied on staff to perform his ADLs and was not able to get out of bed. In an interview with MDS nurse on 8/3/23 at 2pm she said it is a team effort, and all staff work on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 15 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0657 Level of Harm - Minimal harm or potential for actual harm the care plans, with input from DON, ADON, Social Worker, Dietary, and the IDT team meets to discuss care plans appropriate for a resident. She said there are a lot of new staff, and care plans were not complete, so they are trying to update the care plans. She said Quality Monitors were here last week and identified care plans as an issue and gave them a Performance Improvement Plan for care plans (dated 7/28/23). She said they were planning on correcting the care plans as soon as possible. Residents Affected - Some In an interview with the DON on 8/3/23 at 3:10 pm, she said care plans needed to be accurate so residents will get the proper care. She said she knew the care plans were an issue after the Quality monitors were here, and they are working on getting them updated and corrected. Record review of facility policy Comprehensive care Plans, implemented 2/10/21, read, in part: .care planning process will include an assessment of the resident's strengths and needs .comprehensive care plans will be reviewed and revised by the interdisciplinary team . Resident #3 FTag Initiation 08/01/23 01:48 PM on hospice, not on care plan 08/03/23 01:00 PM Resident ordered brace to R foot/ankle and not on CP. Air mattress, turn Q2hr, and off-load L stump ordered. Off-load L stump not on CP. Resident #25 FTag Initiation 08/01/23 01:45 PM 1 rehospitalization 08/03/23 10:30 AM PEG malfunctioned and sent to hospital. PEG Tube not on care plan. On 8/1/23 resident fell and hit head and refused to go to ER x3. Sent to hospital on 8/1/23 for CT head. No bleeding or LOC. 08/03/23 10:58 AM uses hoyer lift to get into w/c. PT recommended on 5/24/23, but no orders in chart. No ADLs in care plan. Moved to rehab tag. Resident #34 FTag Initiation 08/03/23 03:11 PM 08/01/23 01:27 PM limited ROM 08/03/23 09:33 AM Resident able bodied and in w/c. receives PT services. OT/PT services not on care plan. Resident #38 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 16 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0657 FTag Initiation Level of Harm - Minimal harm or potential for actual harm 08/03/23 11:36 AM No R hand splint on CP, or ST/OT services. Resident #65 Residents Affected - Some FTag Initiation 08/03/23 03:25 PM PICC, PT, O2, and Boots not on CP Resident #66 FTag Initiation 08/03/23 01:07 PM No PT until 8/2/23 after Surveyor questioned. No Bariatric chair. Both not on CP. Care Plan is missing ADL interventions and does not have PT on it. Bariatric Chair ordered on 7/20/23. No evidence of chair. Not on CP. Resident #68 Death 08/04/23 09:05 AM full code and DNR both on CP. Hospice name/info not on CP. Resident had leukemia and was actively dying. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 17 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 2 of 4 residents (Residents #27 and, #100) reviewed for pharmacy services, The facility failed to order medications timely which resulted in Resident #27 and #100 missing prescribed medications on 8/2/23. This failure could place residents at risk for worsening health concerns. Findings include: 1. Record review of Resident #27's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE], with diagnoses of Type 2 Diabetes Mellitus (body does not produce enough insulin or it resists insulin), asthma with status asthmaticus (severe asthma unresponsive to inhalers or epinephrine), occlusion and stenosis of right carotid artery (narrowing and hardening of the artery that carry blood from the heart to the brain), bilateral osteoarthritis of the knee (degenerative joint disease causing pain, stiffness, and decreased mobility), and polyneuropathy (peripheral nerves are damaged). Record review of Resident #27's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated normal cognition. She used a wheelchair and required physical assistance with personal hygiene, bathing, and toilet use. According to the MDS, Resident #27 received PRN pain medication and had received them for the previous 7 days. Record review of Resident #27's care plan, revised 4/2/22, stated, Resident #27 is currently taking an anticoagulant related to hypertension. Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Report abnormal lab results to the physician. Monitor/document/report to MD PRN s/sx of anticoagulant complications . Resident #27's care plan also stated, Resident #27 has arthritis. Resident #27 will be/remain free of complications related to arthritis. Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness. The care plan also revealed, Resident #27 is at risk for pain related to arthritis, polyneuropathy. Resident will not have moderate or severe pain through the next review date. Pain or discomfort will be relieved within a timely manner of receiving pain medication or treatments as ordered by the physician. Record review of Resident #27's medical record on 8/2/23, revealed an order for Plavix 75mg 1 PO QAM for occlusion and stenosis of right carotid artery, ordered on 7/6/23 by Dr. M. There was also an order for Tramadol 50mg 1 PO TID for pain, ordered on 4/18/23 by Dr. M. Record review of Resident #27's MAR from July 2023 revealed on 7/31/23 she did not receive the Tramadol 50mg the whole day, and the medication was marked on hold. According to the MAR, her pain level was a 5 out of 10. During medication pass on 8/2/23 at 8:50am, Resident #27 received the following medications from RN M: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 18 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 Artificial Tears 1gtt Both Eyes BID Level of Harm - Minimal harm or potential for actual harm Coreg 6.25mg 1 PO BID Gabapentin 100mg 1 PO TID Residents Affected - Few Gabapentin 800mg 1 PO TID Lisinopril 20mg 1 PO QAM Gemfibrozil 600mg 1 PO BID Fluoxetine 20mg 1 PO QAM Faxiga 10mg 1 PO QAM Sodium Chloride 1g 1 PO QAM In an interview and observation on 8/2/23 at 8:50am, RN M confirmed there were 8 pills in the med cup. Resident #27 asked if her Tramadol was still out of stock. RN M informed her it was, and Resident #27 asked if it was time for her to have more Tylenol instead. RN M informed her she would check. Record review of Resident #27's MAR at about 10:00am on 8/2/23 revealed the Tramadol 50mg was on hold from 8/1/23-8/3/23 and she did not receive it. According to the MAR, on 8/1/23 her pain level was a 5 out of 10 and on 8/2/23 her pain level was an 8 out of 10. The MAR also revealed Resident #27 received Plavix 75mg on 8/1/23 and 8/2/23 by RN M. In an observation and interview with RN M on 8/2/23 at 11:00am, she stated she must have accidentally marked the Plavix as given. RN M went to Resident #27's medication bin and was not able to find any blister packs with Plavix. RN M was not sure when Resident #27 last had Plavix since there were not any blister packs left. RN M went and got the ADON. The ADON and RN M searched the medication room for blister packs of Plavix for Resident #27 but were unable to find any. The ADON told RN M to take Plavix from the emergency supply box to give to Resident #27. When asked again about when Resident #27 received Plavix last, RN M stated she remembered giving Plavix yesterday (8/1/23). RN M was unsure of when the Tramadol was ordered or when it was coming in because she was working as a med aide on 8/2/23 and not as the nurse. In an interview with the ADON on 8/2/23 at 11:15am, she stated it was the nurse's responsibility to ensure the medications got reordered on a timely basis. She stated the blister pack had a blue outline on the last 10 days of pills, which should have signaled to them to order more. The ADON said they then faxed a refill sheet to the pharmacy so the medication could get filled. The ADON stated the nurse's must have not been paying attention and did not order the medication before it ran out. In an interview with RN M on 8/2/23 at 11:30am she stated she called the pharmacy and Resident #27's Plavix would be delivered that night. She also stated she gave the Plavix from the emergency box. RN M did not say when the Tramadol would be in. In an interview with Resident #27 on 8/4/23 at 12:36pm she stated she had received her Tramadol that day. She stated that was the first time the facility had run out of Tramadol, and she went without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 19 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 it for a few days. Resident #27 stated the facility gave her Tylenol to help with the pain while they were out of Tramadol, but it did not help, and her pain continued to be around a 5 out of 10. 2. Record review of Resident #100's undated face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus (body does not produce enough insulin or body is resistant to it), altered mental status, atherosclerotic heart disease of coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), and aortocoronary bypass graft (surgical procedure to treat coronary artery disease). Record review of Resident #100's Quarterly MDS, dated [DATE], revealed a BIMS score of 10 out of 15 which indicated mildly impaired cognition. The resident used a wheelchair and required assistance with bathing, transfer, and mobility. The MDS also revealed Resident #100 had a stage 3 pressure ulcer and was receiving nutrition/hydration to manage it. Record review of Resident #100's care plan, revised 7/11/23, stated, Resident is at risk for infection/signs and symptoms of viral respiratory infection. Resident will not exhibit signs/symptoms of viral respiratory infection through next review date. Observe for and promptly report signs and symptoms: fever, coughing, shortness of breath, or other respiratory issues. It also stated, Resident #100 has a non-pressure wound to the abdomen and is at risk for infection, pain and a decline in functional abilities. Supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Record review of Resident #100's August 2023's MAR revealed he received Pyridoxine HCl 50mg on 8/1/23. Record review of Resident #100's medical record on 8/2/23 revealed an order for Pyridoxine HCl 50mg 1 PO QAM for supplement, ordered on 7/7/23 by NP S. During medication pass on 8/2/23 at 9:26am Resident #100 received the following medications from LVN O: Asprin 81mg 1 PO QD Zinc 50mg 1 PO QD Miralax 17g PO QD Vit C 500mg 1 PO QD Fluticasone 50mcg 1 spray each nostril QAM Coreg 6.25mg 1 PO BID Dicyclomine 20mg 1 PO QAM Divalproex 500mg 1 PO BID Gabapentin 100mg 1 PO BID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 20 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 Paxlovid 150-100mg 2 PO BID Level of Harm - Minimal harm or potential for actual harm In an interview and observation on 8/2/23 at 9:26am, LVN O confirmed there were 9 pills in the med cup. LVN O stated Resident #100 also needed Pyridoxine 50mg, but she did not have any in her med cart. She stated she needed to see what the medication was for and see if there was any in the medication storage room. LVN O also stated Resident #100 had received it yesterday (8/1/23). LVN O was unable to find any in the storage closet. She stated the process was they gave a list of the inventory to the person who orders supplies in HR, since it was an OTC medication. The person who orders supplies in HR typically orders once a week. LVN O stated the nursing staff should have notified her to order more when there were at least 10 pills left. She stated staff must have overlooked how many pills were left or thought there were more bottles somewhere. Residents Affected - Few In an interview with the ADON on 8/2/23 at 11:15am regarding another resident's missing medication, the ADON stated she was aware of Resident 100's missing medication as well. She stated she understood the facility had a problem with not ordering medications in a timely manner and that caused the residents to have missed and/or delayed treatments. Record review of the facility's policy and procedure on Medication Reordering (Revised February 2023) read in part: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. 2. Acquisitions of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting. 4. The nurse that is assigned to each medication cart will perform a medication cross match every Thursday night . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 21 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 11.11%, based on 3 errors out of 27 opportunities, which involved 2 of 4 residents (Residents #27 and #100), and 2 of 3 staff (RN M, and LVN O) reviewed for medication errors, in that: Residents Affected - Few RN M failed to administer 2 medications (Plavix 75mg and Tramadol 50mg) to Resident #27 on 8/2/2023. LVN O failed to administer 1 medication (Pyridoxine 50mg) to Resident #100 on 8/2/23. This failure could place residents at risk for not receiving therapeutic effects of their prescribed medications and possible adverse reactions. Findings include: 1. Record review of Resident #27's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE], with diagnoses of Type 2 Diabetes Mellitus (body does not produce enough insulin or it resists insulin), asthma with status asthmaticus (severe asthma unresponsive to inhalers or epinephrine), occlusion and stenosis of right carotid artery (narrowing and hardening of the artery that carry blood from the heart to the brain), bilateral osteoarthritis of the knee (degenerative joint disease causing pain, stiffness, and decreased mobility), and polyneuropathy (peripheral nerves are damaged). Record review of Resident #27's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated normal cognition. She used a wheelchair and required physical assistance with personal hygiene, bathing, and toilet use. According to the MDS, Resident #27 had received PRN pain medication and had received them for the previous 7 days. Record review of Resident #27's care plan, revised 4/2/22, stated, Resident #27 is currently taking an anticoagulant related to hypertension. Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Report abnormal lab results to the physician. Monitor/document/report to MD PRN s/sx of anticoagulant complications . Resident #27's care plan also stated, Resident #27 has arthritis. Resident #27 will be/remain free of complications related to arthritis. Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness. The care plan also revealed, Resident #27 is at risk for pain related to arthritis, polyneuropathy. Resident will not have moderate or severe pain through the next review date. Pain or discomfort will be relieved within a timely manner of receiving pain medication or treatments as ordered by the physician. Record review of Resident #27's medical record on 8/2/23, revealed an order for Plavix 75mg 1 PO QAM for occlusion and stenosis of right carotid artery, ordered on 7/6/23 by Dr. M. There was also an order for Tramadol 50mg 1 PO TID for pain, ordered on 4/18/23 by Dr. M. Record review of Resident #27's MAR from July 2023 revealed on 7/31/23 she did not receive the Tramadol 50mg the whole day, and the medication was marked on hold. According to the MAR, her pain level was a 5 out of 10. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 22 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0759 During medication pass on 8/2/23 at 8:50am, Resident #27 received the following medications from RN M: Level of Harm - Minimal harm or potential for actual harm Artificial Tears 1gtt Both Eyes BID Coreg 6.25mg 1 PO BID Residents Affected - Few Gabapentin 100mg 1 PO TID Gabapentin 800mg 1 PO TID Lisinopril 20mg 1 PO QAM Gemfibrozil 600mg 1 PO BID Fluoxetine 20mg 1 PO QAM Faxiga 10mg 1 PO QAM Sodium Chloride 1g 1 PO QAM In an interview and observation on 8/2/23 at 8:50am, RN M confirmed there were 8 pills in the med cup. Resident #27 asked if her Tramadol was still out of stock. RN M informed her it was, and Resident #27 asked if it was time for her to have more Tylenol instead. RN M informed her she would check. Record review of Resident #27's MAR at about 10:00am on 8/2/23 revealed the Tramadol 50mg was on hold from 8/1/23-8/3/23 and she did not receive it. According to the MAR, on 8/1/23 her pain level was a 5 out of 10 and on 8/2/23 her pain level was an 8 out of 10. The MAR also revealed Resident #27 received Plavix 75mg on 8/1/23 and 8/2/23 by RN M. In an observation and interview with RN M on 8/2/23 at 11:00am, she stated she must have accidentally marked the Plavix as given. RN M went to Resident #27's medication bin and was not able to find any blister packs with Plavix. RN M was not sure when Resident #27 last had Plavix since there were not any blister packs left. RN M went and got the ADON. The ADON and RN M searched the medication room for blister packs of Plavix for Resident #27 but were unable to find any. The ADON told RN M to take Plavix from the emergency supply box to give to Resident #27. When asked again about when Resident #27 received Plavix last, RN M stated she remembered giving Plavix yesterday (8/1/23). RN M was unsure of when the Tramadol was ordered or when it was coming in because she was working as a med aide on 8/2/23 and not as the nurse. In an interview with the ADON on 8/2/23 at 11:15am, she stated it was the nurse's responsibility to ensure the medications got reordered on a timely basis. She stated the blister pack had a blue outline on the last 10 days of pills, which should have signaled to them to order more. The ADON said they then faxed a refill sheet to the pharmacy so the medication could get filled. The ADON stated the nurse's must have not been paying attention and did not order the medication before it ran out. In an interview with RN M on 8/2/23 at 11:30am she stated she called the pharmacy and Resident #27's Plavix would be delivered that night. She also stated she gave the Plavix from the emergency box. RN M did not say when the Tramadol would be in. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 23 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with Resident #27 on 8/4/23 at 12:36pm she stated she had received her Tramadol that day. She stated that was the first time the facility had run out of Tramadol, and she went without it for a few days. Resident #27 stated the facility gave her Tylenol to help with the pain while they were out of Tramadol, but it did not help, and her pain continued to be around a 5 out of 10. 2. Record review of Resident #100's undated face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus (body does not produce enough insulin or body is resistant to it), altered mental status, atherosclerotic heart disease of coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), and aortocoronary bypass graft (surgical procedure to treat coronary artery disease). Record review of Resident #100's Quarterly MDS, dated [DATE], revealed a BIMS score of 10 out of 15 which indicated mildly impaired cognition. The resident used a wheelchair and required assistance with bathing, transfer, and mobility. The MDS also revealed Resident #100 had a stage 3 pressure ulcer and was receiving nutrition/hydration to manage it. Record review of Resident #100's care plan, revised 7/11/23, stated, Resident is at risk for infection/signs and symptoms of viral respiratory infection. Resident will not exhibit signs/symptoms of viral respiratory infection through next review date. Observe for and promptly report signs and symptoms: fever, coughing, shortness of breath, or other respiratory issues. It also stated, Resident #100 has a non-pressure wound to the abdomen and is at risk for infection, pain and a decline in functional abilities. Supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Record review of Resident #100's August 2023's MAR revealed he received Pyridoxine HCl 50mg on 8/1/23. Record review of Resident #100's medical record on 8/2/23 revealed an order for Pyridoxine HCl 50mg 1 PO QAM for supplement, ordered on 7/7/23 by NP S. During medication pass on 8/2/23 at 9:26am Resident #100 received the following medications from LVN O: Asprin 81mg 1 PO QD Zinc 50mg 1 PO QD Miralax 17g PO QD Vit C 500mg 1 PO QD Fluticasone 50mcg 1 spray each nostril QAM Coreg 6.25mg 1 PO BID Dicyclomine 20mg 1 PO QAM Divalproex 500mg 1 PO BID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 24 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0759 Gabapentin 100mg 1 PO BID Level of Harm - Minimal harm or potential for actual harm Paxlovid 150-100mg 2 PO BID Residents Affected - Few In an interview and observation on 8/2/23 at 9:26am, LVN O confirmed there were 9 pills in the med cup. LVN O stated Resident #100 also needed Pyridoxine 50mg, but she did not have any in her med cart. She stated she needed to see what the medication was for and see if there was any in the medication storage room. LVN O also stated Resident #100 had received it yesterday (8/1/23). LVN O was unable to find any in the storage closet. She stated the process was they gave a list of the inventory to the person who orders supplies in HR, since it was an OTC medication. The person who orders supplies in HR typically orders once a week. LVN O stated the nursing staff should have notified her to order more when there were at least 10 pills left. She stated staff must have overlooked how many pills were left or thought there were more bottles somewhere. In an interview with the ADON on 8/2/23 at 11:15am regarding another resident's missing medication, the ADON stated she was aware of Resident 100's missing medication as well. She stated she understood the facility had a problem with not ordering medications in a timely manner and that caused the residents to have missed and/or delayed treatments. Record review of the facility's policy and procedure on Medication Reordering (Revised February 2023) read in part: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. 2. Acquisitions of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting. 4. The nurse that is assigned to each medication cart will perform a medication cross match every Thursday night . Record review of the facility's policy and procedure on Medication Administration: Oral (Revised 2/10/21) read in part: To administer medication by mouth. 1. Open MAR to patient record and review physician medication order against medication label three times .11. Document medication administration on MAR . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 25 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0760 Ensure that residents are free from significant medication errors. 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 did not ensure residents were free from any significant medication errors for 1 of 4 (Resident #27) residents reviewed for significant medication errors, Residents Affected - Few The facility failed to give Resident #27's Plavix medication, (which is an antiplatelet to prevent clots), because RN M overlooked the order. This failure could place the resident at risk of forming a blood clot which could cause a stroke, heart attack, or death. Findings included: Record review of Resident #27's undated face sheet revealed she was a [AGE] year-old female readmitted on [DATE], with diagnoses of Type 2 Diabetes Mellitus (body does not produce enough insulin or it resists insulin), asthma with status asthmaticus (severe asthma unresponsive to inhalers or epinephrine), occlusion and stenosis of right carotid artery (narrowing and hardening of the artery that carry blood from the heart to the brain), bilateral osteoarthritis of the knee (degenerative joint disease causing pain, stiffness, and decreased mobility), and polyneuropathy (peripheral nerves are damaged). Record review of Resident #27's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated normal cognition. She used a wheelchair and required physical assistance with personal hygiene, bathing, and toilet use. Record review of Resident #27's care plan, revised 4/2/22, stated, Resident #27 is currently taking an anticoagulant related to hypertension. Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Report abnormal lab results to the physician. Monitor/document/report to MD PRN s/sx of anticoagulant complications . Record review of Resident #27's medical record on 8/2/23, revealed an order for Plavix 75mg 1 PO QAM for occlusion and stenosis of right carotid artery, ordered on 7/6/23 by Dr. M. During medication pass on 8/2/23 at 8:50am, Resident #27 received the following medications from RN M: Artificial Tears 1gtt Both Eyes BID Coreg 6,25mg 1 PO BID Gabapentin 100mg 1 PO TID Gabapentin 800mg 1 PO TID Lisinopril 20mg 1 PO QAM Gemfibrozil 600mg 1 PO BID (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 26 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0760 Fluoxetine 20mg 1 PO QAM Level of Harm - Minimal harm or potential for actual harm Faxiga 10mg 1 PO QAM Sodium Chloride 1g 1 PO QAM Residents Affected - Few In an interview and observation on 8/2/23 at 8:50am, RN M confirmed there were 8 pills in the med cup. Record review of Resident #27's MAR on 8/2/23 at about 10:00am revealed she received Plavix 75mg on 8/1/23 and 8/2/23 by RN M. In an observation and interview with RN M on 8/2/23 at 11:00am, she stated she must have accidentally marked the Plavix as given. RN M went to Resident #27's medication bin and was not able to find any blister packs with Plavix. RN M was not sure when Resident #27 last had Plavix since there were not any blister packs left. RN M went and got the ADON. The ADON and RN M searched the medication room for blister packs of Plavix for Resident #27 but were unable to find any. The ADON told RN M to take Plavix from the emergency supply box to give to Resident #27. When asked again about when Resident #27 received Plavix last, RN M stated she remembered giving Plavix yesterday (8/1/23). In an interview with the ADON on 8/2/23 at 11:15am, she stated it was the nurse's responsibility to ensure the medications were reordered on a timely basis. She stated the blister pack had a blue outline on the last 10 days of pills, which should have signaled to them to order more. The ADON said they then faxed a refill sheet to the pharmacy so the medication could get filled. The ADON stated the nurse's must have not been paying attention and did not order the medication before it ran out. She also stated she understood the facility had a problem with not ordering medications in a timely manner and that caused the residents to have missed and/or delayed treatments. In an interview with RN M on 8/2/23 at 11:30am she stated she called the pharmacy and Resident #27's Plavix would be delivered that night. She also stated she gave the Plavix from the emergency box. Record review of the facility's policy and procedure on Medication Reordering (Revised February 2023) read in part: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. 2. Acquisitions of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting. 4. The nurse that is assigned to each medication cart will perform a medication cross match every Thursday night . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 27 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide specialized rehabilitative services for 2 of 18 (Residents #65 and #66) residents reviewed for specialized rehabilitative services, Residents Affected - Few The facility failed to ensure Residents #65 and #66 received physical therapy and as per physician orders, after being readmitted to the facility. This failure could place residents with orders for therapy at risk of not meeting their highest practicable well-being. Findings include: 1. Record review of Resident #65's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE] with diagnoses of paraplegia (paralysis from waist down), cirrhosis of liver (liver damage), alcoholic hepatitis with ascites (liver damage with fluid in the stomach from excessive alcohol), and hypertension (high blood pressure). Record review of Resident #65's MDS, dated [DATE], revealed a BIMS score of 14 out of 15 which indicated normal cognition. The resident was bedbound and required extensive assistance with personal hygiene, toilet use, dressing, and bed mobility, and was totally dependent for bathing. Resident #65 had impairment to both lower extremities. Record review of Resident #65's care plan, dated 7/19/23, revealed Resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. Resident will participate to the best of their ability and maintain current level of functioning with ADLs through the next review date. The interventions were not complete. Physical Therapy was not care planned. Record review of Resident #65's medical record on 8/3/23 revealed an order for Physical Therapy to screen. May evaluate as needed ordered on 6/29/23 by Dr. G. There was also an order for PT Eval and Tx as indicated on 7/7/23 by Dr. G. Record review of Resident #65's PT Evaluation and Plan of Treatment revealed he was seen on 7/7/23 and the plan was for him to be seen 3xweek for 30 days, signed by PT KS on 7/8/23. According to records resident was sent to the hospital on 7/11/23 and came back to the facility on 7/18/23. Resident #65 was not re-started on Physical Therapy. In an interview with Resident #65 on 8/1/23 at 10:41am, he stated he had not received PT since he had been back from the hospital. He stated he had received a little bit of PT before he went to the hospital, but nothing had been done since he had been back on 7/18/23 and he just laid in bed all day. In an interview with CMA A and CMA H on 8/3/23 at 12:42pm, they stated they were unable to get residents out of bed until PT evaluated them and said they were safe to do so. They could not get Resident #65 into the facility's wheelchair unless PT performed a wheelchair evaluation and said he was safe to get into one. They stated as far as they knew, that had not been done yet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 28 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review of Resident #66's undated face sheet revealed he was a [AGE] year-old male readmitted on [DATE], with diagnoses of cerebral infarction (stroke), hypertension (high blood pressure), and Type 2 Diabetes Mellitus (body doesn't produce insulin or body is resistant). Record review of Resident #66's MDS dated [DATE], revealed a BIMS score of 13 out of 15 which indicated normal cognition. The resident was bedbound and required extensive assistance with personal hygiene, toilet use, dressing, and bed mobility. He was totally dependent on transferring, locomotion on and off the unit, and with bathing. Resident #66 had impairment to both lower extremities. Record review of Resident #66's care plan initiated 7/11/23, revealed Resident has an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. Resident will participate to the best of their ability and maintain current level of functioning with ADLs through the next review date. The interventions were left blank and not filled out. Physical Therapy was not care planned. Record review of Resident #66's medical record on 8/2/23 revealed an order for Physical Therapy to screen. May evaluate as needed ordered by Dr. G on 6/30/23. There was also an order for PT Eval & Tx as indicated ordered on 7/7/23 by Dr. G. Record review of Resident #66's PT Evaluation and Plan of Treatment revealed he was seen on 7/7/23, and the plan was to be seen 3xweek for 30 days, signed by PT KS on 7/10/23. According to the Physical Therapy notes, Resident #66 was seen for therapy on 7/7/23, 7/12/23, 7/13/23, 7/17/23, 7/19/23, 7/20/23, and then was discharged from PT because he was sent to the hospital. The resident was readmitted to the facility on [DATE] and was not restarted on PT. In an interview with Resident #66 on 8/1/23 at 11:03am, he stated he had a stroke and had not been receiving PT. He stated that he had been out of bed once, but nothing since then. He also said he could not move his body from waist down. In an interview with the PT Director on 8/4/23 at 2:28pm, he stated it was their process to restart PT within 1-2 days after the resident was readmitted . He stated that he had been on vacation and had just gotten back, but his Manager and Regional Therapist should have been covering for him. The PT Director stated they were in the facility the previous week and must have dropped the ball when it came to Resident #65 and #66's PT orders. He also stated it was important to keep residents on PT/OT/ST so they did not have a decline in their mobility/ability and ADLs. A policy on Therapy was requested from the Administrator on 8/3/23 at 3:00pm, but they did not have one. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 29 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and safeguard against transmission of legionella and waterborne pathogens for 1 or 1 facility water systems. Residents Affected - Many The facility failed to establish and provide documentation for a water management program as part of the infection control program. This failure could place residents at risk for Legionnaires' disease (a serious type of lung infection caused by Legionella bacteria which can live in standing water within facility water systems) and other waterborne pathogens. Findings included: Interview on 08/04/23 at 11:45am with the MS, he said the facility was equipped with backflow prevention devices to ensure separation of clean and dirty water. He said the facility does not have a water management program for the surveillance of waterborne pathogens. He said he does not know what legionella was and was not familiar with waterborne pathogens that could impact the residents. Interview on 08/04/2023 11:50am with the ADM, she said staff was not aware of the need for a water management program. She said that she would check with the county about water management and monitoring, but no internal management program. The ADM said she was not familiar with Legionella, but any type of infection could pose a risk to the resident population and will be addressed promptly. Interview on 08/04/2023 at 12:00pm with the DON, she said that she has heard of legionella bacteria , but not very familiar with it. She said there have been no cases of Legionnaires' disease in the facility to her knowledge. The DON said that she would educate herself and the team concerning symptoms of Legionella infection, but is certain that it could pose a health risk to an already vulnerable population. Record review of the facility's Infection Prevention and Control Program policy (04/12/2023) revealed the following: 16. Water management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program. Record review of Legionella Surveillance Policy (07/01/2023) revealed in relevant part: It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 30 of 31 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 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 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 0880 2. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies. Level of Harm - Minimal harm or potential for actual harm 5. Primary prevention strategies: Residents Affected - Many a. Diagnostic testing b. Investigation for a facility source of Legionella, which may include culturing of a facility water for Legionella c. Physical controls d. Temperature controls FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 31 of 31