Inspection·February 5, 2026

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's discharge summary included an accurate reconciliation of all pre-discharge medications with post-discharge medication for 1 of 1 Residents reviewed for discharge medication reconciliation. The facility failed to complete an accurate reconciliation of medications for Resident #1 when he was discharged home on 1/31/2026. This failure could place residents at risk for discontinuity of care after being discharged from the facility to their home. Findings include:Record review of Resident #1's face sheet dated 2/2/2026 showed a [AGE] year old male was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (a medical condition where a patient experiences complete paralysis or weakness on the left side of the body because of a cerebral infarction, commonly known as a stroke, affecting the non-dominant hemisphere of the brain), bipolar disorder (a condition characterized by extreme mood swings including periods of mania and depression), type 2 diabetes mellitus (a chronic disease that is characterized by high levels of sugar in the blood), and cognitive communication deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes, rather than a primary problem with language or speech). Record review of progress notes showed that Resident#1 was discharged from the facility to his responsible party's home on 1/31/2026. There was a physician order to discharge Resident#1 received by the facility on 1/30/2026 that read, may discharge home with sister POA with scheduled medications no narcotics and all other belongings. Record review of a document titled Medications Released on Leave of Absence that was saved in Resident #1's electronic record as discharge medication list and signed on 1/31/2026 by the DON and resident's responsible party did not list insulin as a medication sent home with Resident #1. Record review of Resident #1's active orders at the date and time of discharge on [DATE] indicated the following orders for insulin:1. Humalog injection solution (Insulin Lispro). Inject 5 IU subcutaneously two times a day for DM. Hold for BS less than 100. Order date 1/23/2026. Discontinue date 2/2/2026.2. Insulin Glargine Solution 100 unit/ml. Inject 30 units subcutaneously two times a day for diabetes. Hold for BS less than 80. Order date 1/23/2026. Discontinue date 2/2/2026.Record review of Resident #1's care plan with an initiation date of 10/27/2025, listed DM as a focus with interventions that included to monitor and document for side effects and effectiveness of diabetic medication as ordered and listed Insulin Glargine as a medication that Resident #1 is receiving.Interview with the DON on 2/4/2026 at 10:40 am revealed she had been working as the DON since April 2024 and worked the shift when Resident #1 was discharged from the facility. The DON stated that she gathered Resident #1's scheduled medications except his narcotics and gave them to Resident #1's responsible party and they both signed a discharge medication list. She stated she didn't think Resident #1 had insulin prescribed, and if he did, she would have sent home the insulin as well.Interview with LVN A on 2/4/2026 at 1:47 pm (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675052 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 02/05/2026 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)