Inspection·November 13, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few placed on one-on-one monitoring. RP DON, Administrator notified. Elopement in-service started immediatelySide Door Code changed immediately. Smoking policy and instruction to ensure door security. Interview on 11/6/25 at 9:57 am with Resident #1's Family Member said was notified that Resident #1 eloped. She said the facility had suggested a transfer to a secure location after the elopement, but she did not want the transfer. Observation and interview on 11/6/25 at 10:40 a.m., Resident #1 lying in his bed awake, groomed and presenting no odors or visible injuries. When asked how he was doing, he said fine. No additional questions, including questions about the elopement, were not answered. Observation and Interview on 11/6/25 at 9:25 a.m., the DON said that through the facility investigation, they found that Resident #1 eloped due to Resident #2 propping the door open when she went out to smoke. She said there was no police report filed that the police officer just brought him back to the facility and the police were contacted by a household across the street. She added that Resident #1 was assessed and had no injuries. She said they placed him on one-on-one monitoring. Educated Resident #2 on propping the doors open and performed audit checks on all residents with wander guards. All staff were in-services on elopements, supervision, and smoking rules. She said that the facility had a meeting and believed there was a PIP but would wait for the Administrator to provide that information. The DON was asked to show the area and route Resident #1 eloped to and the door that was propped open at the time was observed, the route and house that Resident #1 eloped to was directly across the street. Interview with the Administrator on 11/6/25 at 11:15 am, she stated that through the facility investigation, they found that Resident #1 eloped due to Resident #2 propping the door open when she went out to smoke. She said Resident #1 was assessed and had no injuries no police report was filed the police officer returned the Resident #1. She said they placed him on one-on-one monitoring. Educated Resident #2 on propping the doors open and performed audit checks on all residents with wander guards. All staff were in-serviced on elopements, supervision, and smoking rules. She said they checked all doors for malfunctioning alarms and there were no issues found, she said the facility hired a new maintenance director, but that person had not started yet. She said that the facility also changed codes to all doors with keypads, in-serviced staff on entry and exit to the facility, making sure the door was completely closed and the staff would have to punch a key code in to allow entrance back into the facility. She said that the facility performed a PIP and would provide the surveyor with all documentation. Observation and interview on 11/13/25 at 11:45 a.m. Resident #2 was in her room, sitting in bed eating dry cereal. She said that she was trained in safe smoking including propping doors. She denied doing propping the door open and said that she remembered something about Resident #1 eloping but did not remember the details. Interview on 11/13/25 at 1:21 p.m., with the Administrator and Director of Clinical Operations added to the interview via telephone at 1:38 pm confirming Performance Improvement Plan on 8/23/25 8/31/25 to ongoing which was attended by the Administrator, DON, and Medical Director. Record review of facility's elopement policy dated revised 1.17.18, 6/23/25; 7/1/25, entitled Wanderer Management, Monitoring System & Resident Elopement Protocol read in part. Purpose:To monitor safety of residents at risk for elopement.to provide a system to alert staff that a resident may be attempting to leave the facility.Policy.It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible.Responsibility.All staff is responsible to ensure resident safety. On 11/13/25 at 1:21 p.m., the Administrator was notified of past noncompliance IJ. A plan of removal was not requested. An IJ template was provided on 11/13/25 at 1:21 pm to the administrator in person and via email with signature requested. The facility implemented the following interventions prior to the surveyor : Record review of the facility completed a Performance Improvement Plan dated 8/23/25 to 8/31/25 to (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 11/13/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few which was attended by the Administrator, DON, and Medical Director indicated the following topics were discussed:1. Elopement wandering/leaving the facility training.2. Abuse/neglect training,3. Resident right rights training4. Updated the elopement book and care plans.5. Audit and maintenance check of all residents with wander guards Performance improvement plan with immediate intervention which included:1. Head count,2. Resident returned to facility within 20 minutes and immediately placed on one-on one monitoring by staff.3. Medical Director/RP notified4. Head to assessment completed5. Wandering/elopement evaluation for resident #1-updated.6. Audit on all residents to identify residents at risk for elopement. 7. All smokers re-trained about smoking policy including not to prop doors open. 8. All staff trained on monitoring/supervision and assuring doors are not ajar when smokers go out to smoke. Record review of one-on-one monitoring dated 8/22/25 through 8/25/25 revealed Resident #1 received one-one monitoring from 8/22/25 through 8/25/25. Record review of the Elopement wandering/leaving the facility training in-services dated 8/23/25-8/25 indicated all staff attended the in-services indicated they were in-serviced on abuse and neglect, monitoring/supervision residents, responsibilities to monitor doors on both shifts to insure they are closed, the change of codes to doors and that no one other than staff are allowed to have the codes to doors, elopement policy and procedure, supervision or residents who smoke, wander guard residents monitoring and procedures. Interviews conducted on 11/6/25, 11/12-11/13/25 from various times throughout the investigation the Administrator, AIT, DON, Director of Clinical Operations, the Activity Director, The Social Worker, LVN A, LVN B, RN A, CNA B, CNA C, Med Aide A, The Shower Aide, The Dietary Manager, [NAME] and Kitchen Aide with indicated they were in-serviced on abuse and neglect, resident rights, monitoring/supervision residents, responsibilities to monitor doors on both shifts to insure they are closed, the change of codes to doors and that no one other than staff are allowed to have the codes to doors, elopement policy and procedure, supervision or residents who smoke, wander guard residents monitoring and procedures. Record review of the Abuse/neglect training in-service dated 8/22/25-8/26/25 revealed all staff received in-services on Abuse and Neglect. Interviews conducted on 11/6/25, 11/12-11/13/25 from various times throughout the investigation the Administrator, AIT, DON, Director of Clinical Operations, the Activity Director, The Social Worker, LVN A, LVN B, RN A, CNA B, CNA C, Med Aide A, The Shower Aide, The Dietary Manager, [NAME] and Kitchen Aide with indicated they were in-serviced on abuse and neglect, resident Rights monitoring/supervision residents, responsibilities to monitor doors on both shifts to insure they are closed, the change of codes to doors and that no one other than staff are allowed to have the codes to doors, elopement policy and procedure, supervision or residents who smoke, wander guard residents monitoring and procedures. Record review of the facility elopement book revealed all residents with wander guards had been re-assessed and had measures in place to prevent elopement. Record review of the care plans indicated Resident #1 care plans were revised on 8/25/25 to address the actual elopement. Record review of the Audit and maintenance check of all residents with wander guards indicated there were no issues. Record review of Resident #1's clinical record revealed a Head to assessment was completed on 8/21/25 . Record review of the Wandering/elopement evaluation for Resident #1 was updated on 8/22/25. Record review the facility Audit on all residents to identify residents at risk for elopement was completed on 8/21/25-8/22/25. Record review of the facility documentation of All smokers re-trained on smoking policy including not to prop doors open was completed on 8/25/25. Record review of the monitoring/supervision/redirecting of residents and assuring doors are not ajar when residents that smoke go out in-service dated 8/22/25-8/23/25 indicated all staff were trained. This noncompliance was identified as Past Non-Compliance Immediate Jeopardy (IJ) . The IJ began on 8/21/25 and ended on 8/31/25. The facility corrected the noncompliance (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 11/13/2025 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 0689 by having implemented actions that corrected the non-compliance prior to surveyor entrance. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675052 If continuation sheet Page 4 of 4