Health inspection·September 11, 2024

F 0550 o Sexual assessment to be completed by clinical nurse and social worker. Level of Harm - Minimal harm or potential for actual harm Date Initiated: 01/23/2024. Residents Affected - Some o Ensure that the sexual relations are consensual and document the findings in the medical record of both residents. Consent means both residents decide together to do the same thing, at the same time, in the same way, with each other. o Sexual education to be provided. -Educate the resident on the risks associated with sexual relations such as sexually transmitted diseases and pregnancy. -Encourage the resident to discuss their sexual history with their potential partner prior to becoming sexually active. o Provide a private, non-confrontational environment for the two residents. o Make condoms available for the residents to use if they so desire. o Notify the resident's physician of any signs/symptoms of an STD: Resident # 66 Record review of Resident #66's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included Blindness, essential (primary) hypertension, PTSD, mood disorder, cognitive communication, obesity, anxiety disorder, chronic type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), depression, lack of coordination and muscle weakness. Record review of Resident #66's face sheet revealed she was her own responsible party. Record review of Resident #66's annual MDS assessment dated [DATE] revealed she had a BIMS score of 15, which indicated her cognition was intact. On ADL care she was coded as limited assistant. Record review of Resident #66's Care plan dated 01/23/23 revealed Resident # 66 was care planed asResident #66 engages in voluntary consensual sexual activities with another resident. Date Initiated: 01/23/2024 Revision on: 04/15/2024. Goal: Resident #66 will respect their sexual partner and obtain consent each time prior to engaging in sexual relations through the next review date. Date Initiated: 01/23/2024 Target Date: 01/12/2025. Intervention: o Ensure both residents are their own responsible party and have not been deemed incapacitated by a physician. Date Initiated: 01/23/2024. o Sexual assessment to be completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 2 of 14 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 09/11/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some o Ensure that the sexual relations are consensual and document the findings in the medical record of both residents. Consent means both residents decide together to do the same thing, at the same time, in the same way, with each other. Date Initiated: 01/23/2024. o Sexual education to be provided. -Educate the resident on the risks associated with sexual relations such as sexually, transmitted diseases and pregnancy. -Encourage the resident to discuss their sexual history with their potential partner prior to becoming sexually active. Date Initiated: 01/23/2024. o Psychological Services as ordered. Date Initiated: 01/23/2024. o Provide a private, non-confrontational environment for the two residents. Date Initiated: 01/23/2024. o Make condoms available for the residents to use if they so desire. Date Initiated: 01/23/2024. o Notify the resident's physician of any signs/symptoms of an STD. Resident #44 Record review of Resident #44's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included essential hypertension, anxiety disorder, depression, pain, cognitive communication deficit, and muscle weakness, Record review of Resident #44's annual MDS assessment dated [DATE] revealed she had a BIMS score of 15, which her cognition was intact. On ADL care she was coded as limited\minimum assistant. Observation and interview on 09/09/24 at 2:00PM, revealed Resident #44 smoking together with Residents #42 and #66. Resident #66 introduced Resident #42 as her boyfriend, and they had been together for a long time. During an interview, Resident #66 said Resident # 44 (roommate to Resident #66) had to leave her room when he visits Residents #66 which is not right. He said they have been asking to put them together in the same room for over a year and the only answer was Roommate of Resident # 66 can give them privacy if she wants to. Resident #66 said the facility does not provide privacy for the residents. Resident #42 said he does not feel comfortable for Resident #44 to leave her room so that Resident # 66 and Resident #42 can have a private time together. Observation and interview on 09/11/24 at 10:00AM, revealed Resident #44 was observed alone in her room. She said her roommate was moved on 09/10/24. During an interview with Facility administrator on 09/10/24 at 2:00PM, she said there was no room available for a male and female because all their rooms had jack and Jill bathroom and the facility was watching out for other residents' privacy as well. The Administrator said Resident #44 agreed to give Residents # 42 and #66 privacy for 2 hours. She said the facility had also offered to discharge Residents #42 and #66 to an assisted living facility that would accommodate both resident in a room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 3 of 14 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 09/11/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some together, but they refused. She said she would look to see if she could find a room for both residents. She said this had been going on before her time at the facility. Record review of facility's admission policy dated 02/23/16 revised 02/20/21 titled Resident Rights read in part The Facility shall protect and promote the rights of each Resident, including each of the following rights: The Resident has the right to a dignified existence, self-determination, communication with and access to, persons and services inside and outside the Facility. The Resident has a right to exercise his or her rights as a Resident of the Facility and as a citizen or resident of the United States. The Resident has the right to be free of interference, coercion, discrimination, or reprisal from the Facility in exercising his or her rights . The Resident has a right to choose activities schedules and health care consistent with his or her interests, assessments, and plans of care. The Resident has a right to participate in social, religious, and community activities that do not interfere with the rights of other Residents. The Resident has a right to reasonable accommodation of individual, needs and preferences except where the health or safety of the Resident or other Residents would be endangered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 4 of 14 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 09/11/2024 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's transfer, reentry, discharge, and death for 8 of 16 residents (CR #79, Residents #9, #33, #44, #66, #50, #75, #382) reviewed for electronic transmission of MDS data to the CMS system. Residents Affected - Some 9The facility failed to complete and transmit CR 79, Residents #9, #33, #44, #66, #50, #75, #382 MDS assessment within 14 days of the ARD date. These failures could place residents at risk of not having their assessments completed and submitted in a timely manner and having their Medicaid payments and/or services interrupted. Findings include: Resident #9 Record review of Resident #9's face sheet, dated 09/10/24, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included Generalized abdominal pain, primary pulmonary hypertension, anxiety disorder, overactive bladder, muscle weakness, major depressive disorder, history of falling, muscle wasting, and atrophy. Record review of Resident #9's annual MDS assessment with ARD date of 05/16/24 was completed on 05/16/24 and transmitted on 6/12/24, 27 days after the ARD date. Resident #33 Record review of Resident #33's clinical record revealed admission date 4/3/24 with diagnoses including cerebral infarction (loss of oxygen in the brain), dysphagia (swallowing disorder), hemiplegia and hemiparesis (paralysis and weakness on one side of the body), Diabetes (inability of body to regulate blood sugar), Cirrhosis of liver (chronic liver damage causing liver failure), hypertension (high blood pressure), major depressive disorder (persistently depressed mood). Record review of Resident #33's admission MDS with ARD target date of 4/8/24 was completed and transmitted 37 days late, on 5/15/24. Resident #44 Record review of Resident #44's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included essential hypertension, anxiety disorder, depression, pain, cognitive communication deficit (refer to difficulties in communication that result from impaired functioning of cognitive processes) and muscle weakness. Record review of Resident #44's annual MDS assessment with ARD date of 12/01/23 was completed on 01/12/24, 42 days after the ARD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 5 of 14 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 09/11/2024 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 0640 Resident #50 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #50's clinical record revealed admission date 3/24/23 with diagnoses including cerebrovascular disease (condition affecting blood flow to the brain), bipolar disorder (mood swings from depressive lows to manic highs), anxiety disorder (worry, fear, anxiety affecting daily life), aphasia (language disorder), dysarthria (speech disorder), hemiplegia (paralysis on one side of the body). Residents Affected - Some Record review of Resident #50's Annual MDS with ARD date of 3/29/24 was completed 5/10/24 and transmitted 5/13/24 42 days after the ARD date. Resident # 66 Record review of Resident #66's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included essential (primary) hypertension, PTSD , mood disorder, anxiety disorder, chronic type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), depression, lack of coordination and muscle weakness. Record review of Resident #66's annual MDS assessment with ARD date of 11/21/23 was completed on 12/11/23 and transmitted on 12/12/23, 20 days after the ARD date. Resident #75 Record review of Resident #75's clinical record revealed admission date 6/20/24 with diagnoses including hypertension (high blood pressure), cerebral infarction (stroke), dysphagia (swallowing problem), diabetes (inability of body to regulate blood sugar), chronic kidney disease (longstanding kidney disease causing kidney failure), hemiplegia (paralysis on one side of the body, aphasia (language disorder). Record review of Resident #75's admission MDS with ARD date of 6/27/24 was completed and transmitted 17 days late on 7/15/24. CR #79 Record review of CR #79's Face Sheet dated 09/11/24 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included senile degeneration of brain (is the mental deterioration and loss of intellectual ability), diabetes, major depressive disorder, kidney failure, and anxiety. Record review of CR #79's clinical records revealed the last MDS assessment on his clinical record was dated ARD of 07/14/24 and was coded as death in facility. The MDS was completed 07/22/24 and was submitted 08/01/24, 18 days after the ARD. Resident #382 Record review of Resident 382's clinical chart revealed admission date 8/8/24 with diagnoses including anoxic brain damage (death of brain cells after 4 minutes of lack of oxygen to the brain), heart failure (failure of heart to pump blood efficiently). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 6 of 14 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 09/11/2024 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 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #382's admission MDS with ARD date of 8/21/24 was completed 15 days late on 9/5/24 and transmitted 9/19/24. In an interview on 9/11/24 at 2:05 pm, the MDS nurse said the former MDS nurse passed away in February of this year, and corporate nurses were filling in until March when she took over the job. A PRN MDS nurse was hired to train her because she was not familiar with the job, and she started working with MDS assessments in April. She said she knew the MDS assessments were late, but she is working on getting them caught up and making them accurate for the residents. She said the risk of not submitting assessments on time would affect the residents' plan of care and receiving proper care. In an interview on 9/11/24 at 2:45 pm, the Administrator said the former MDS nurse passed away in February, and they have been trying to get the MDS assessments caught up. She said the risk of not having timely assessments would be improper care for the residents. Record review of the CMS RAI manual, Chapter 5, dated 2023 revealed in part, .the admission assessment RAP completion date can be no more than 14 days from the date of admission .for all other comprehensive MDS assessments, the RAP completion date may be no later than 14 days from ARD .discharge and re-entry records must be completed within 7 days of the event date . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 7 of 14 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 09/11/2024 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 observation, interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program to the maximum extent practicable for 1 of 5 residents (Resident #57) reviewed for PASRR. -The facility failed to update the PASRR Level 1 forms for Resident #57 to indicate mental health illness. This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility. Findings included: Record review of Resident #57's face sheet dated 09/11/2024 revealed that Resident # 57 is a 69 -year-old female who admitted to the facility on [DATE] and had an active diagnosis of Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) with an onset documented as of 04/16/2024. Record review of the PASRR Level 1 Screening for Resident #57 dated for 03/29/2024 indicated no mental health illness. It was determined that resident was not eligible for PASRR specialized services because serious mental illness was not documented on admission, at the time of Resident 57 initial PASRR Level 1 Screening. Record review of Resident #57 care plan dated 09/10/2024 read in part Resident #57 uses psychotropic medications (antidepressants, antipsychotics, anxiolytics, or hypnotics) related to depression, generalized anxiety disorder, bipolar disorder. Observation and interview on 09/09/2024 at 10:00 AM, revealed Resident #57 lying in bed watching TV. She stated that she received her medications but did not know what medications she had been taking. Resident #57 denied receiving any services and support related to coping with bipolar disorder. Resident denied being sad at the time of the interview. Interview on 09/10/2024 at 2:00 PM, the Social Worker stated she was responsible for completing the PASRR. She confirmed that Resident #57' PASRR Level 1 on admission was negative for mental illness, The Social Worker stated that Resident #57 was diagnosed with bipolar disorder as of 04/16/2024. Social Worker stated that she did not know that she had to submit an updated PASSR Level 1 indicating that Resident #57 had an active diagnosis of bipolar disorder. The Social Worker stated that she had not received any training regarding PASRR. The Social Worker did not reveal how she monitored to ensure it PASRR Level 1 assessments were completed timely and accurately . She did not know why the referral had not been completed on 04/16/2024 and she said that it would be important for a resident to receive PASRR services if they qualified. The Social Worker said that the potential risk to a resident for not having the corrected referral submitted to identify mental health illness, would be that the resident would not receive the necessary services qualified for. Record review of the facility's Resident Assessment-Coordination with PASRR Program policy dated implemented 06/2023 and Date Revised: 06/2023 revealed 9. Any resident who exhibits a newly evident or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 8 of 14 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 09/11/2024 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 possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review .b. A resident whose intellectual disability or related was not previously identified and evaluated through PASRR. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 9 of 14 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 09/11/2024 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 3 of 16 residents (Residents #9, #42, #66) reviewed for dental services. Residents Affected - Some The facility failed to provide proper routine dental care for Residents # 9, #42 and #66. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Resident #9 Record review of Resident #9 ' s face sheet, dated 09/10/24, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included Generalized abdominal pain, primary pulmonary hypertension, anxiety disorder, overactive bladder, muscle weakness, major depressive disorder, history of falling, muscle wasting, and atrophy. Record review of Resident #9 ' s annual MDS assessment with ARD date of 05/16/24 revealed she was coded for a BIMS score of 15 which indicated she was cognitively intact. Record review of section L of the MDS oral dental section revealed she was assessed as having Obvious or likely cavity or broken natural teeth. Record review of Resident #9 ' s care plan dated 12/08/20 revealed Resident #9 was care planed as Resident #9 had likely carious teeth and is at risk for pain and infection. Goals: The resident will comply with mouth care at least daily through next review date Date Initiated: 12/08/2020, Revision on: 09/11/2024, Target Date: 06/12/2025. The resident will be free of infection, pain, or bleeding in the oral cavity through next review Date Intervention: Provide mouth care as per ADL personal hygiene. Monitor and report to MD PRN any s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), abscess, debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Inspect oral cavity during oral care and report changes to the nurse Administer medications as ordered. Monitor for side effects and effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 10 of 14 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 09/11/2024 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 0791 Refer to dentist for evaluation and recommendations. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #9 ' s weight record from June through September revealed no significant weight loss. Residents Affected - Some Observation and interview on 09/10/24 revealed Resident #9 was in bed alert and oriented. She said she was doing well. She said her teeth has been hurting her for sometimes. She said all her right-side hurts and she can only eat on the left side of her mouth. She said she had complained but nothing was done. She said she manage as much as she can. Observation revealed she was missing some of her teeth in her upper and lower cavity. She said she had also told her responsible party about her pain. She said she had not seen a dentist since her admission. Resident #42 Record review of Resident #42's face sheet, dated 09/10/24, reflected a [AGE] year-old male, who admitted to the facility on [DATE]. Her diagnoses included Essential hypertension (high blood pressure), type 2 diabetes mellitus with anxiety disorder, major depressive disorder, lack of coordination, and muscle weakness. Record review of Resident #42 ' s annual MDS assessment dated [DATE] revealed he had a BIMS score of 15, which indicated his cognition was intact. Record review of section L oral /dental section reflected he was coded as Obvious or likely cavity or broken natural teeth. Record review of Resident # 42 ' s care plan revealed. Resident #42 was care as · Resident #42 has oral/dental health problems carious teeth / broken teeth r/t Poor oral hygiene Goal: Staff will provide oral care at least daily through next review date. Date Initiated: 11/26/2022 Revision on: 09/05/2024, Target Date: 02/28/2025 Resident will comply with mouth care at least daily through next review date Date Initiated: 11/26/2022, Revision on: 09/05/2024 Interventions: Provide mouth care as per ADL personal hygiene. Date Initiated: 11/26/2022 Monitor and report to MD PRN any s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Date Initiated: 11/26/2022. Inspect oral cavity during oral care and report changes to the nurse. Date Initiated: 11/26/2022 Observation and interview on 09/09/24 at 2:00PM, revealed Resident #42 was outside smoking with Resident #66 and #44. Observation revealed he had missing teeth on his lower and upper oral cavity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 11 of 14 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 09/11/2024 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview he said he has been asking to see a dentist, but no one would listen to him. He said he had told the Social Worker several times but she never came back to give him an answer.Resident # 66 Record review of Resident #66's face sheet, dated 09/10/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included essential (primary) hypertension, PTSD, mood disorder, anxiety disorder, chronic type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), depression, lack of coordination and muscle weakness. Record review of Resident #66 ' s annual MDS assessment dated [DATE] revealed she had a BIMS score of 15, which indicated her cognition was intact. Record review of section L of her oral/dental section revealed she was assessed as having obvious or likely cavity or broken natural teeth. Record review of Resident #66 ' s Care plan dated 01/23/23 revealed no evidence of care plan for her dental care. Observation and interview on 09/09/24 at 2:00PM, revealed Resident #66 was outside smoking with Resident #42 and #44. Observation revealed she had missing teeth. During an interview she said she has been asking to see a dentist, but no one would listen to her. She said she had expressed having pain in her gums and teeth, but it all falls on deaf ear ' . She said she had told the social worker several times that she had pain in her gum. She said she had not heard from her about her dental referral. Observation and interview with Resident # 66 on 09/09/24 at 1:30pm revealed Resident # 66 had missing teeth in her oral cavity. She said she was supposed to see a dentist but has not heard from the social worker and no one had discussed her dental issue since she complained of pain. She said she had loose teeth and pain when she shews on her right side. During an interview with the social worker on 09/10/24 at 3:00PM, she said she does not assess residents for their dental but would refer them to the dentist if they complained. She said there was no dentist that visit residents at the facility. She said had asked some to come but they would schedule but not show up. She said she remembered Resident #9 ' s responsible party had asked her in the past to refer Resident #9 to a dentist. She said she did not have any documentation. During an interview with MDS coordinator on 09/10/24 at 4:00PM, she said she did the assessment on resident ' s oral dental section and the social Worker did the referral. She said Resident ' s care areas are usually discussed during the care plan meeting and any acute care was done by the nurses. During an interview with the Facility ' s Administrator on 09/11/24 at 4:00Pm, she said the facility does not have a dentist that visits residents at the facility. She said some of the insurance providers had their own dentist that visit their residents and the facility is actively looking for a dentist who would visit residents on a regular basis. Policy on routine and emergency dental care services was requested but was not provided prior to exit on 09/11/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 12 of 14 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 09/11/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that left over food items in the walk-in cooler, were properly sealed, and labele with opened, expiration date. This failure could affect the residents who received meals from the kitchen and could place them at risk for foodborne illness. Findings included: Observation of the facility's only kitchen on 09/09/24 at 8:24AM revealed one of one walk in cooler in the kitchen had the following food items unlabeled and undated. All food items were identified by the Dietary Manager. -¾ left over cake unlabeled and undated -Can sliced apples in a plastic container partially covered. -Food items in a grocery bag unlabeled and undated. The Dietary Manager said it was a TV Dinner and it belonged to a resident. -An unidentified food product in a grocery bag. The Dietary Manager said she does not know what it was. -Left over salad in a Ziplock bag. -Flour tortillas identified as [NAME] by the dietary manager. -3 and 3/4 gallons of chocolate milk with the manufacture date of use before 09/08/24. During an interview with the Dietary Manager on 09/09/24 at 10:00AM, she said all left over food items and food products out of the original containers are to be labeled and dated. She said serving expired milk to residents may lead to food borne illness and she would not use it. During an interview with the facility administrator on 09/10/24 at 3:00Pm. She said she expected all food items in the walk-in freezer and refrigerator to be labeled and dated. She said the dietary department was a vending company. Record review of the policy titled Frozen and refrigerated food storage dated 08-2005 review 7/22/22 read in part, Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered. Most pick stickers do have the delivery date on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 13 of 14 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 09/11/2024 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 0812 sticker. They must also be dated with an expiration date unless they have one from the manufacturer ( that is milk cartons, eggs) Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 14 of 14