Health inspection·February 20, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #38's physician orders dated for 2/2025 revealed: Admit to [Hospice Company] (Dx: Cerebral Infarction) 1/11/2025. Record review of Hospice Company contract revealed home health aide, nurses, social work, and chaplain would be provided, with daily care to be provided by the nursing facility. l Residents Affected - Some Observation and attempted interview with Resident #38 on 2/18/25 revealed she was in bed, awake, clean, and was not responding to questions. Resident #17 Record review of Resident #17's face sheet revealed a [AGE] year-old male with admission date of 4/3/24 and diagnoses including end stage renal disease (loss of kidneys to remove waste and balance fluids), Diabetes (inability of the body to control glucose in the blood), vascular dementia (decline in thinking skills), major depressive disorder (persistent depressed mood or loss of interest), peripheral vascular disease (poor circulation due to narrow blood vessels in legs), acquired absence of left leg below knee. Record review of Resident #17's physician orders dated for 2/2025 revealed: Resident to receive dialysis 3 days a week MWF . chair time 11:00a.m. Record review of Resident 17's Significant Change MDS dated [DATE] revealed BIMS 13 out of 15 which indicated modified independence in cognitive skills for decision making, usually understood and understands, moderate to maximum assistance for ADLs, and Dialysis. Record review of Resident #17's undated comprehensive care plan revealed no focus, goals, or interventions for Dialysis. Observation and interview with Resident #17 on 2/18/25 at 10:15am revealed he was sitting in his wheelchair outside the nurses' station. He had a warm coat and a scarf across his shoulders and told surveyor he was going outside and to Dialysis and wanted to be warm. In an interview with MDS nurse on 2/20/25 at 2:30pm revealed if the resident just got on hospice, it would not be on the care plan for 90 days since she does care plans every 90 days. She said the risk of having inaccurate care plans would be they would not get the right care. In an interview with the DON on 2/20/25 at 2:40pm, she said she did not know why the Hospice or Dialysis were missed on the care plan. She said the nurses have input into the care plans and they let the MDS nurse know of any changes, and the MDS nurse would incorporate it into the comprehensive care plan. She said the risk of having inaccurate care plans would be things would not get done for the resident, and it would not be on the [NAME]. Resident #19 Record Review of Resident #19's face sheet dated 2/20/25, revealed resident is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, and Hemiplegia (One-Sided Paralysis or Weakness of the Face, Arm and Leg) and Hemiparesis (One-Sided Muscle Weakness caused by Brain, Spinal Cord or Nerve Problems) Following Cerebrovascular Disease (Disorders that affect blood flow to the brain) Affecting Left Dominant (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 02/20/2025 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 0656 Side. Level of Harm - Minimal harm or potential for actual harm Record review of Resident's #19's quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. Residents Affected - Some Record review of Resident #19's care plan revealed that The resident had a cerebral vascular accident (CVA/Stroke) affecting left side which is not correct as Resident 19 has had a cerebral vascular accident (CVA/Stroke) affecting her right side. Record review of Resident #19's occupational therapy notes for certification period of 11/9/24 to 1/7/25 revealed that resident had impaired right upper extremity strength and left upper extremity strength was within functional limits. Record review of Resident #19's doctor's progress note dated 2/14/2025 revealed that Resident #19 had an old CVA (Stroke) with right hemiparesis (One-Sided Muscle Weakness caused by Brain, Spinal Cord or Nerve Problems) listed under the past medical history section. Observation and Interview on 2/18/25 at 11:33 a.m. revealed that Resident #19 could not move her right arm during observation of 10 minutes while initial pool questions were being asked by surveyor. Resident #19 said she had done physical therapy but not in the last couple of months. During an interview on 2/19/25 at 11:31 a.m., the Director of Rehab said that Resident #19 was on physical therapy at the time of the interview. During an interview on 2/19/25 at 2:12 p.m., LVN G said that Resident #19's right arm was the arm she had difficulty moving. During an interview on 2/19/25 at 2:12 p.m., CMA G said that Resident #19's right arm was the arm she had difficulty moving. During an interview on 2/19/25 at 2:13 p.m., the DON said that Resident #19's right arm was the arm she had difficulty moving. During an interview on 2/19/25 at 2:13 p.m., the ADON said that Resident #19's right arm was the arm she had difficulty moving. During an interview on 2/19/25 at 3:45 p.m., Resident #19 said her right arm had been affected by a stroke in 2019, and she was unable to move her right arm. Resident #19 denied ever having any deficit in her left arm as was documented in Resident #19's care plan. During an interview on 2/19/25 at 3:45 p.m., Resident #18 Family said that Resident #19 had difficulty moving her right arm, and it occurred when she had a stroke in 2019. During an interview on 2/20/25 at 8:49 a.m., the ADON said the MDS nurse entered information into the residents' care plans. During an interview on 2/20/25 at 8:50 a.m., the DON said the MDS nurse entered information into the resident's care plans. (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 02/20/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/20/25 at 9:19 a.m., Casemix Specialist A said she was the MDS nurse, but her title was Casemix Specialist. Casemix Specialist A said that care plan information was entered by the MDS nurse. Casemix Specialist A said that the information for left hemiplegia on Resident 19's care plan was initially entered by Casemix Specialist B who was the Casemix Specialist at the time. Casemix Specialist A said that she reviewed the resident's care plans every 90 days but generally reviewed things that were acute and going to change. Casemix Specialist A said she was familiar with Resident #19 and that her right side was affected. Record review of the facility's policy Care Plans, Comprehensive Person Centered revealed, in part: Care plans describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being .to identify professional services responsible for each resident's care . and Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Also, assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Care Plans, Comprehensive Person-Centered policy was reviewed November 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675052 If continuation sheet Page 4 of 4