Inspection·March 13, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 03/13/24 at 10:06 a.m., revealed the Administrator went inside Resident #1's room for approximately 1 minute, turned off the call light, and then came out of her room. The Administrator said the resident told her she had a bowel movement and needed to be changed. Observation and interview on 03/13/24 at 10:06 a.m., revealed Resident #1 was lying in bed. She said she needed to be changed. She said the wait time for staff to change her varied. She said sometimes she had to wait for staff to finish helping other residents and sometimes staff came right away. She said staff would be there soon to change her. There were no odors in the room. Observation on 03/13/24 at 10:11 a.m., revealed the Activities Director entered Resident #1's room and came out shortly after. Observation on 03/13/24 at 10:14 a.m., revealed the Activities Director asked CNA C, who was walking toward Hall #2, to help her change Resident #1. They entered the resident's room and closed the door. In an interview on 03/13/24 at 7:45 a.m., CNA B said Nurse A, MA A, and herself were assigned to hall #2. In an interview on 03/13/24 at 2:27 p.m., the Activities Director, who said she was also a CNA, said she had been working at the facility since 10/2023. She said her work hours were 9:00 a.m. to 5:00 p.m. but she would arrive around 8:20 a.m. She said in the past she helped with answering call lights, changing residents, getting the residents up, and with the resident's overall ADL care. She said she felt at times they had enough staff on the floor and at other times not enough staff. She said the staff on hall #2, Nurse A, CNA B and MA A, did not let her know they were going to be unavailable to answer call lights. She said she was not sure how long Resident #1's call light was on. She said she asked Resident #1 how long she had been waiting and the resident told her she had it on since after breakfast. She said she felt there were not enough staff on the floor today. She said as far as she was aware, the facility tried to call in additional staff to help when needed and that they did not use agency. She said she was not considered a floater but helped when she was needed. In an interview on 03/13/24 at 3:15 p.m., the DON said she felt there was enough nursing staff on shift. She said that MA A and the Activities Director were also CNAs, and Transportation/Floater was a CNA and MA. She said if a resident was a two person assist and both staff were assisting 1 resident together, they knew they should have informed the other nursing staff on hall #1. In an interview on 03/13/24 at 4:08 p.m., CNA B said she was assisting Resident #2 with his care between 9:00 a.m. and 10:00 a.m. when Nurse A walked in with the resident's wound care stuff. She said Nurse A closed the door and when she finished assisting the resident, she helped Nurse A with his wound care. She said it did not take that long to do his wound care, approximately 15 minutes. She said after they finished, Nurse A left, and she stayed behind to gather the linens and move his table back which took approximately an additional 7 minutes. She said she did not ask Nurse A if she let anyone know that they were going to be in the resident's room. She said no call lights were going off when she went in Resident #2's room. She said when she came out, they told her they changed Resident #1 for her. She said she checked on Resident #1 first thing this morning at approximately 7:45 a.m. and between 8:30 a.m. and 9:00 a.m. She said after the last time she checked on Resident #1, she got pulled into Resident #2's room. She said sometimes she felt they were understaffed and sometimes not. She said she normally told the MA, nurse, or someone else that she was going to be helping a resident. She said if it took 2 of them to assist a resident, she would let hall #1 know if help was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675052 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Ridge Healthcare Center 208 South Utah LA Porte, TX 77571 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 0677 needed. She said she had 19 residents on Hall #2. Level of Harm - Minimal harm or potential for actual harm In an interview on 03/1324 at 4:29 p.m., the Administrator said the census determined the facility's staffing needs. She said they got so many hours per day based on the residents' needs because the census could change daily. She said typically, it was a ratio for the resident vs. staff member. She said she was always a little bit overstaffed because she had people in different departments that she could use on the floor. She said she hired people with multiple certifications i.e., the Activities Director was a CNA and transportation had her CNA and MA certifications. She said today her 3 CNAs were CNA B, CNA C, and CNA D/ Floater who did transportation as well. She said she did not have 3 CNAs on the floor right now. She said staffing needs would always be based on residents because even with the patient per day ratio it was always based on the number of residents. She said they have not had to use agency in a long-time because they had enough permanent staff and staff that would pick up shifts. She said she followed the hourly patient per day ratio of residents vs. staff member. Residents Affected - Few In an interview on 03/13/24 at 4:38 p.m., the DON said CNA D was at the facility this morning but left at 7:00 a.m. to take a resident to an appointment. She said she was not on the floor right now because she just left and took a resident to the ER for a change in condition but not a 911 change in condition. In an interview on 03/13/24 at 4:50 p.m., MA A said she remembered that Resident #1's call light went off a couple of minutes before she started her medication pass. She said she checked on Resident #1 and she said she wanted to get changed. She said she told her she would go and find her CNA and turned off the call light. She said she found CNA B who was in Resident #2's room. She said she told CNA B when she was finished with Resident #2, Resident #1 wanted to be changed. She said she was not able to change Resident #1 because she started her medication pass. She said Resident #1's call light went off a second time, but she did not answer it because she was in the middle of medication pass. She said she did not let another staff member know because she thought in her mind that CNA B was going to go down to Resident #1's room and change her. She said as a rule, if a call light was going off, she would stop what she was doing as long as she did not pop that first pill because she did not want to make a medication error. She said they have been told they were supposed to find someone to help when needed. She said she did not tell anyone help was needed because she thought CNA B was going to Resident #1's room after a few minutes. She said she was not aware that Resident #1's call light was going off for 30 minutes. She said she thought the breakdown was that no one was conscious of the time. She said there was usually 3 CNAs working on the floor but today there were only a total of 2 CNAs on the floor. She said this could have potentially resulted in a breakdown of the skin on Resident #1's bottom. In an interview on 03/13/24 at 5:20 p.m., Nurse A said Resident #1's light was not going off prior to going and doing wound care for Resident #2. She said CNA B was already in Resident #2's room and she had CNA B assist her with Resident #2's wound care. She said she did not recall hearing a beep going off when she came out of Resident #2's room to get xeroform from the medication cart. She said she did not tell anyone that CNA B and she were going to be doing wound care, but she said she was told by the Administrator, afterwards, to let Administration know so they could hang out on the hallway to assist residents with whatever they needed while they were tied up with resident care. She said she did not feel there was enough staff on the floor. In an interview on 03/13/24 at 5:55 p.m., CNA D/Transportation/Floater said she was certified to transport residents, was a CNA, and a MA. She said she arrived at the facility today at approximately 5:15 a.m. She said when she arrived, she put and made sure supplies were on the CNAs carts and got a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675052 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675052 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bay Ridge Healthcare Center 208 South Utah LA Porte, TX 77571 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few couple of residents up. She said she left the facility at approximately 6:30 a.m. to transport Resident #3 to the cardiologist and arrived back to the facility between 8:30 a.m. and 9:00 a.m. She said when she got back to the facility, she assisted Hall #1. She said between 12:00 p.m. and 12:30 p.m. she left and took Resident #4 to a doctor's appointment and returned at approximately 12:40 p.m. She said she helped pass and pick up meal trays on Hall #1 and #2. She said she then left at about 1:15 p.m. to take Resident #5 to the hospital to see the wound doctor and returned back to the facility between 2:30 p.m. and 3:00 p.m. She said she was on the floor on Hall #1 helping CNA C with the residents for less than 1 hour and then had to leave at approximately 4:00 p.m. to transport Resident #6 to the ER. She said she returned to the facility at approximately 4:45 p.m. and started picking up trays and helped change residents in Hall #1 and #2. In an interview on 03/13/24 at 6:28 p.m., the Administrator said she was not aware Resident #1's call light was on for 30 minutes. She said when she checked on Resident #1, she asked her if she had her call light on for a while and she said yes. She said she told her she would get someone to assist her, turned off her call light, and immediately got the Activities Director to assist the resident and change her sheets. She said she told Nurse A that in times that they knew they were going to do wound care to give administration a forewarning so she could have a staff member in place. She said it was a one off. She said if they communicated, they would cover each other to help. She said a 30-minute situation where it was going to be both of them going in could eliminate the wait and could get someone else to assist. She said her expectation was that everyone could answer call lights, and if any department could handle what a resident needed then they should handle it and if they could not handle it, they need to keep the call light on and find someone that could. She said this could have potentially affected Resident #1's dignity, but this happened to be a one-off situation. In a follow-up interview on 03/13/24 at 6:50 p.m., the DON said she was not aware Resident #1's call light went unanswered for 30 minutes. She said this could potentially have led to a risk for skin breakdown. Record review of the facility's nursing schedule, dated 03/13/24, revealed Nurse A (Hall #2), Nurse B (Hall #1), CNA B (Hall #2), CNA C (Hall #1), CNA D/Transportation/Float, and MA A were scheduled for the 6:00 a.m. to 6:00 p.m. shift. Record review of the facility's staffing posting, dated 03/13/24, revealed a census of 41 and a staff total of 1 RN, 1 LVN, 1 CMA, and 3 CNAs during the day. Record review of the facility's policy titled Staffing, Sufficient and Competent Nursing, reviewed 03/2023, read in part .Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments, and the facility assessment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675052 If continuation sheet Page 4 of 4