Inspection·May 8, 2023

F 0609 Record review of completed PIR for was signed by the DON on 4/19/2023. Level of Harm - Minimal harm or potential for actual harm In an interview on 05/03/2023 at 9:57am with the CRN, she said that she was a RN and had work for the corporate office in her current position for two years. She said that she discovered that the completed PIR for the incident involving Resident #2 and CR #1 was not submitted to the SSA timely while going through a stack of documents, and she had the DON submit it on 05/02/2023. She said that the PIR should have been submitted within 5 days on 04/19/2023 as indicated in the policy for Abuse and Neglect. She said that the oversight for completing the task belonged to the Administrator who is the Abuse Neglect Coordinator. She said the facility was without an Administrator from 03/31/2023-04/16/2023. She said that Admin #1 was at the facility from 4/10/2023-4/14/2023, she completed the investigation, and she left instructions for the DON to submit the PIR to the SSA in her absence. She said that Admin #2 started his position on 04/17/2023, and he claimed that he was not made aware of an outstanding PIR that needed to be submitted to the SSA. She said that the risk of not completing or submitting investigation to the SSA timely is the abuse or neglect could continue. Residents Affected - Few In an interview on 05/03/2023 at 11:04am with the DON, she said that she is an RN and she started her current position on 03/31/2023. She said that Interim Admin was the abuse coordinator at the time the incident was investigated, and it was the responsibility of Interim Admin to submit the completed PIR to the SSA. She said she was not aware that the PIR was not submitted until 05/02/2023, when the CRN told her to submit it to the SSA. She said that a completed PIR should be submitted to SSA within 5 days according to facility policy. She said the PIR for the incident involving Resident #2 and CR #1 was not submitted timely, and she was never made aware that she needed to submit it to SSA. She said that that risk of not completing investigations and not having the completed PIR submitted to the SSA is that the alleged abuse could continue and happen to other residents. In an interview on 05/03/2023 at 11:37am with Admin#2, he said that he started his current position on 04/17/2023, and he was not told about any outstanding PIR that needed to be submitted to the SSA. He said that a completed PIR should be submitted to the SSA in 5 days. He said that the Administrator or designee (DON) should submit completed PIR to the SSA. He said that the risk is resident safety because interventions to prevent further abuse may not be put in place. In a phone interview on 05/03/2023 at 3:35pm with the Interim Admin, she said that she works for the facility's corporate office as a traveling Administrator when there is a vacancy. She said that she was at the facility for a number of days at the beginning of April of 2023, and she believed that her last day was on 04/13/2023. She stated that while she was at the facility, she completed two PIR's, was unsure of the intake numbers, but she was only able to submit one to the SSA. She stated that she left instructions for Admin #2 to submit the second PIR to the SSA. She said that she did not talk to Admin #2, but she left detailed instructions for a number of things that he would need to complete on his start date, and she did not thing think he would have problems being an experienced Administrator. She said that the PIR was not due to the SSA until 4/18/2023 or 4/19/2023. She said the DON was in charge from her last day on 4/13/2023 until 4/17/2023 when Admin #2 started. She said that a completed PIR should be submitted to the SSA in 5 days, and the risk to residents by not doing so is that abuse or neglect could continue. Record review of the facility's undated policy titled Abuse and Neglect Policy and Procedure, read in part: . Report/Respond 1. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source or abuse is reported, the facility Administrator, or his/her designee, will notify the Department of Aging and Disabilities Services (immediately upon learning of the incident and a written investigation no later than the fifth working day after the oral report . ). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 2 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that assessments accurately reflected the resident's status for 1 of 11 residents (Resident#3) whose assessments were reviewed in that: Residents Affected - Few -Resident#3's MDS did not reflect his indwelling catheter. This failure could affect residents at the facility who had been assessed and could contribute to inadequate care. The findings included: Record review of Resident #3's undated face sheet revealed he was [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of end stage renal disease (condition in which kidneys cease functioning). Record review of facility report of current residents with catheters to included Resident#3. Record review of Resident #3's comprehensive care plan with start date 10/25/2022 and revisions on 04/20/2023 revealed: Focus: I require an indwelling urinary catheter R/T Neurogenic Bladder & Chronic H/O Urinary Retention. Goal: I will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. Intervention: Change catheter per MD order. Provide catheter care per MD orders and as needed. Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed Resident#3 was cognitively intact with a BIMS score of 11 in section C. He was not triggered for an indwelling catheter in section H for Bladder and Bowel. In an interview on 05/05/2023 at 10:38pm with the CRN, she said that the CCM completes all MDS assessments, with the DON as oversight oversite. She said that the risk to residents of an inaccurate MDS is that appropriate care may not be received. She said that the facilities used the RAI when completing MDS assessments. In an interview on 05/05/2023 at 11:49am with the DON, she said that the CCM completes all MDS assessments, with her as oversight. She said that the risk of an inaccurate MDS is that residents may not receive appropriate care. She said that she was not sure if the facility used the RAI manual when completing MDS assessments, and she was not familiar with MDS assessments. In an interview and observation on 05/05/2023 at 5:15pm with Resident#3, he was observed in his room with indwelling catheter with a privacy cover. He said that he has had a catheter since admission. In a follow up interview and observation on 05/08/2023 at 1:40pm with the CCM, she reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 3 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #3's Quarterly MDS assessment dated [DATE]. She said that Resident#3 was not triggered for an indwelling catheter in section H for Bladder and Bowel, and said it was an oversite as the resident was admitted with a catheter. She said that she did not know how she missed it. She stated that the risk of not having an accurate assessment is the resident may not receive appropriate care needed. Record review of policy entitled MDS Completion and Submission Timeframes dated July 2017 read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . Record review of CMS RAI 3.0 User's Manual dated October 2019 read in part Section H: Bladder and Bowel Planning for Care o Care planning should include interventions that are consistent with the resident's goals and minimize complications associated with appliance use o Care planning should be based on an assessment and evaluation of the resident's history, physical examination, physician orders, progress notes, nurses' notes and flow sheets, pharmacy and lab reports, voiding history, resident's overall condition, risk factors and information about the resident's continence status, catheter status, environmental factors related to continence programs, and the resident's response to catheter/continence services. Steps for Assessment 1. Examine the resident to note the presence of any urinary or bowel appliances. 2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 4 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 11 residents (CR#4) reviewed for care plans, in that: -CR#4 did not have a completed baseline care plan completed within 48 hours of admission. -CR#4 did not have a baseline care plan to address her indwelling catheter. These failures could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care. Findings included: Record review of CR #4's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included orthopedic aftercare and left leg femoral fracture. Her discharge date was 04/26/2023 to be transferred to another facility. Record review of CR#4's admission Observation Report dated 04/10/2023, indicated CR#4 admitted with indwelling catheter. Record review of CR #4's baseline care plan dated 04/14/2023 and completed by the CCM did not address focus, goals, or intervention for an indwelling catheter. Record review of CR #4's MDS assessment dated [DATE] and completed by the CCM revealed CR #4 was cognitively intake with a BIMS score of 12 in section C. She was triggered for an indwelling catheter in section H for Bladder and Bowel. In an interview on 05/05/2023 at 10:38pm with the CRN, she said that the admitting nurse is responsible for completing the baseline care plan for newly admitted residents within 48 hours. She said upon her review the admitting nurse, LVN D, did not complete the baseline care plan timely, it was completed on 04/14/2023 by the CCM, and the CCM did address that CR#4 had a catheter on the care plan. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT met meet regarding CR#4. She said that the IDT should consist of the CCM, DON, ADON, and DOR. She said that the DON is the oversite oversight and should ensure that all admission tasks are completed accurately. She stated that the risk to residents of not having systems in place could cause residents to not receive appropriate care, delay in diagnosis, delay in treatment, and infection to include UTI. In an interview on 05/05/2023 at 11:01am with the CCM, she said that she is an LVN. She said that she has worked at the facility since 09/01/2022, she completes all MDS assessments for the facility. She said that the admitting nurse is responsible for completing baseline care plan for newly admitted residents within 48 hours. She said the ADON checks for accuracy of the admission process. She stated that the IDT consists of the DON, ADON, CCM, DOR, and SW, and the IDT meets Monday-Friday, and review admission process for newly admitted residents. She said that she helps the ADON audit baseline care plans, and the ADON and she will complete the care plan if had not been completed within 48 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 5 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0655 Level of Harm - Minimal harm or potential for actual harm hours. She said that upon her review CR#4 admitted to the facility with catheter on 04/10/2023, the baseline care plan was not completed until 04/14/2023, and it did not address that the resident had a catheter. She said completed the baseline care plan while completing audits on 04/14/2023. She said that she could not remember if the IDT meet met regarding CR#4. She stated that the risk of not having the systems in place could cause a resident to not receive appropriate care. Residents Affected - Few In an interview on 05/05/2023 at 11:49am with the DON, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the ADON is the oversite oversight to ensure that admitting nurse completed the admission process with accuracy. She said that the CCM is the oversite oversight for to ensure that baseline care plans are completed timely and accurately within 48 hours. She said that she is the oversite oversight for the ADON and CCM. She stated that she completes an audit twice each week to ensure that the admitting nursing and ADON have completed the admission process accurately, she could not remember if she audited the records for CR#4, and she did not keep a record of her audits. She stated that IDT meets to discuss newly admitted residents a few days after admission. She said that she could not recall if the IDT reviewed the admission process for CR#4. She said that based on her review the baseline care plan was not completed timely and did not address the catheter for CR#4. She stated that the risk to the resident of not having systems in place is not receiving appropriate care. In an interview on 05/04/2023 at 12:57pm with the ADON, she said that she is a LVN , and she has worked at the facility for 16 months. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the baseline care plan should be completed in 48 hours. She stated that she audits the admission process the next business day for accuracy and completion. She said that the CCM will help her audit the baseline care plans. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet regarding CR#4. She said that CR#4 was admitted on [DATE] with a catheter. She said she did not work on 04/11/2023-04/12/2023, and she worked the floor for the remaining days of the week. She said that the DON is the oversight oversite, and if she is not able to audit the DON is to complete the task. She said that upon her review the baseline care plan for CR#4 did not address her catheter and was not completed timely. She stated that the risk of not having the system in place is that a resident may not receive appropriate care. Record review of the facility's policy titled Care Plans - Baseline dated 2001 Med-Pass, Inc. (Revised December 2016) read in part. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. - Policy Interpretation and Implementation. 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 6 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0655 Record review of the facility's policy titled, IDT Daily PPS meeting Agenda dated January 2023 read in part. Level of Harm - Minimal harm or potential for actual harm Purpose Statement: To provide on-going communication with the IDT members to discuss the plan of treatment and to assure required procedures are completed in a timely manner for all new admission. Frequency: Meets daily. Team Members: The Interdisciplinary team members (IDT) include but not limited to the following: CCM, Therapy representative, Business office Manager, DON or designee, and social services or designee Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 7 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 5 residents (CR#4) reviewed for incontinent care in that: -The facility failed to document treatment orders and collect the urine sample for CR #4 for three days after order was given on [DATE] after experiencing altered mental status, the resident was transferred to another facility on [DATE], and confirmed to have an UTI. This failure could place residents with urinary catheters at risk for discomfort, trauma, and possibly urinary tract infections. The findings included: Record review of CR #4's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that included orthopedic aftercare and left leg femoral fracture. Her discharge date was [DATE] to be transferred to another facility. Record review of CR#4's admission Observation Report dated [DATE] and completed by LVN D, indicated CR#4 admitted with indwelling catheter. Record review of CR #4's physician order summary report dated [DATE]-[DATE] revealed that there were no orders entered addressing residents' treatment for a catheter. Record review of CR #4's MAR dated from [DATE] revealed no information addressing residents' treatment for a catheter. Record review of CR #4's baseline care plan dated [DATE] and completed by the CCM did not address focus, goals, or intervention for an indwelling catheter. Record review of CR #4's MDS assessment dated [DATE] revealed CR #4 was cognitively intact with a BIMS score of 12 in section C. She was triggered for an indwelling catheter in section H for Bladder and Bowel. Record review of urinary intake/out worksheet for CR#4 revealed that staff tracked output each shift from [DATE]-[DATE]. Record review of progress note dated [DATE] completed by NP read in part, .Chief Complaint/Nature of Present Problem: SNF/ f/u. Reported that patient has been hallucinating at times. UA is still pending. Patient is pending transfer. Due to recent mental status change we will go ahead and check patient's ammonia level and UA C&S. If negative will consult psychiatry Record review of CR#4's discharge summary report dated [DATE] did not indicate that there were any outstanding labs for CR#4 to test for UTI. Record review of CR#4's laboratory order history report undated indicated the UA ordered [DATE] had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 8 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0690 a status of collection pending, no results. Level of Harm - Actual harm Record review of CR #4's medical records from a local hospital dated [DATE] revealed that CR#4 was admitted to the hospital on [DATE] and discharged on [DATE], while admitted CR#4 was confirm with a UTI. Records revealed that CR#4 expired while at the hospital on [DATE] with a preliminary cause of death of acute hypoxemic respirator failure. Residents Affected - Few In an interview and observation on [DATE] at 9:08am with LVN A, she said that she has worked at the facility since [DATE], and she usually works the 6am-6pm shift. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that she had not completed a baseline care plan since she started her position, and they are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that CR#4 was admitted with a catheter, it was removed, but she could not remember the date of removal. She said that she completed catheter care for CR#4, and she documented the tasks in the EMR. She said that on [DATE] CR#4 started hallucinating, she notified the NP, the NP ordered a UA to check for an UTI, and she sent the order to the lab. She did she did not collect the sample, because the lab only picked up on Tuesday and Thursday, with the exception of stat orders, and the NP did not order the UA stat. She said that she told LVN B to collect the sample on the 6pm-6am shift, so that the sampled could be picked up on [DATE], and she entered a progress note. She said that when she started her shift on [DATE] LVN B told her that she collected the sample. She said that CR#4 discharged on [DATE]. She reviewed the physician order summary report, baseline care plan, and MAR for CR#4. She said that the documents did not address the catheter for CR#4. She said that based on the progress notes the admitting nurse was LVN D, and there were no orders entered at the time of admission to address the catheter for CR#4. She said that she could not remember what orders were being used when providing catheter care. She stated that without the orders entered there was no place to capture catheter care on the MAR, and she had no documentation that she completed the tasks. She reviewed the progress notes and said that she did not enter a progress note that LVN B would [NAME] CR#4 UA. She reviewed the laboratory order history report, and said the labs were still pending. She stated that the risks to CR#4 not receiving the UA was an untreated UTI. She stated that the risk of not entering physician orders and completing the baseline care plan upon admission is not receiving appropriate care. In a phone interview on [DATE] at 9:44am with the Relative, she said that CR#4 admitted to the facility with a catheter, she expressed concern with the tube of the catheter being red, and the NP just gave an order to remove the catheter. She said that after the catheter was removed the CR#4 start hallucinating, and the NP order labs to see if CR#4 had a UTI on [DATE]. She said that staff never took the sample, and CR#4 was discharge with the sample never being taken on [DATE]. She said that CR#4 was taken to a new facility on [DATE], the sample was collected, diagnosed with an UTI, and started on antibiotics. She said that CR#4 was sent to the hospital on 05/02//2023 after she fainted and had respiratory problems. She said that while at in the emergency room CR#4 was eating, choked, was revived, placed on a ventilator, but continued to decline. She said that CR#4 died while in the hospital, and hospital was looking to see if the resident was septic. She said that the facility delayed getting the urine sample for CR#4, and that caused a delay in treatment for the UTI. In an interview on [DATE] at 10:38pm with the CRN, she said that the admitting nurse is responsible for entering the physician orders and baseline care plan for newly admitted residents. She said upon her review, LVN D did not entering physician orders for catheter care for CR#4, so catheter care was not included on the MAR for nursing staff to chart that care was provided. She said that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 9 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0690 Level of Harm - Actual harm Residents Affected - Few facility has a standard ordered for catheter care that should have been entered upon admission. She said if there was no documentation enter that the tasks were completed. She said that the baseline care plan was completed on [DATE] by the CCM, but catheter care was not included. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet met regarding CR#4. She said that the IDT should consist of the CCM, DON, ADON, and DOR. She said that the DON is the oversite oversight and should ensure that all admission tasks are completed accurately. She said that LVN B should have ensured that the urine sample was collected for CR#4 on [DATE], LVN B disclosed that she failed to collect the sample because the resident did not have urine output on the shift and based on her review LVN B failed to document the efforts to collect the sample. She was not sure if LVN B contacted the doctor of CR#4, and she was not aware that the sample had not been collected until SSA requested documentation. She stated that the risk to residents of not having systems in place could cause residents to not receive appropriate care, delay in diagnosis, delay in treatment, and infection to include UTI. In an interview on [DATE] at 11:01am with the CCM, she said that she is an LVN. She said that she has worked at the facility since [DATE], she completes all MDS assessments for the facility. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said the ADON checks for accuracy of the admission process. She stated that the IDT consists of the DON, ADON, CCM, DOR, and SW, and the IDT meets Monday-Friday, and review admission process for newly admitted residents. She said that she could not remember if the IDT meet regarding CR#4. She said that she helps the ADON audit baseline care plans, and the ADON and she will complete the care plan if had not been completed within 48 hours. She said that CR#4 admitted to the facility with catheter. She reviewed the baseline care plan, physician orders summary report, and MAR for CR#4. She said that the documents did not address the catheter for CR#4 from admission, and it was missed by everyone. She said that it should have been caught by anyone that needed to chart catheter for the resident. She stated that the risk of not having the systems in place could cause a resident not to receive appropriate care, and with out appropriate catheter a resident could get an infection. In an interview on [DATE] at 11:49am with the DON, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that the ADON is the oversite oversight to ensure that admitting nurse completed the admission process with accuracy. She said that the CCM is the oversite for ensure that baseline care plans are completed timely and accurately. She said that she is the oversite for the ADON and CCM. She stated that she completed an audit twice each week to ensure that the admitting nursing and ADON have completed the admission process accurately, she could not remember if she audited the records for CR#4, and she did not keep a record of her audits. She stated that IDT meets to discuss newly admitted residents a few days after admission. She stated that she could not recall if IDT reviewed the admission process CR#4. She said that if physician orders are not entered the tasks will not be triggered for documentation on the MAR. She stated that CR#4 did not have admission orders for a catheter, and it was not care planned. She said that LVN D was the admitting nurse and she was terminated on [DATE] after she did not show for two shifts that week. She said that LVN B attempt to collect a urine sample for CR#4 on [DATE], the resident did not have urine output, and LVN B failed to document efforts to collect the sample. She said that she was not sure if LVN B called the physician to inform that the sample had not been collected. She said that LVN B should have notified the physician as the physician could have given a new order to collect the sample (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 10 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0690 Level of Harm - Actual harm by an alternative method, since the resident did not have output. She was not aware that the sample had not been collected until SSA requested documentation. She stated that the risk to the resident of not having systems in place is not receiving appropriate care a delay in diagnosis of the UTI, resident could have had delay in treatment, and that could have resulted in hospitalization. Residents Affected - Few In a phone interview on [DATE] at 12:30pm with LVN B, she said that she has worked at the facility since September of 2022, and she works the 6pm-6am shift. She said that she remembered CR#4. She said that during shift change on [DATE] LVN A told her that the doctor ordered a urine sample for labs for the resident. She said she did not collect the sample because CR#4 did not have urine output during the shift. She said that she could not remember if she called the physician. She said she would like to be able to review her documentation before she answered anymore questions, and she would be at the facility for a shift on [DATE] at 6pm. In an interview on [DATE] at 12:57pm with the ADON, she said that she is a LVN, and she has worked at the facility for 16 months. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She stated that she audits the admission process the next business day for accuracy and completion. She said that CR#4 was admitted on [DATE] with a catheter. She said that she did not work on [DATE]-[DATE], and she worked the floor for the remaining days of the week. She said that the DON is the oversite, and ifs is not able to audit the DON is to complete the task. She said that she reviewed physician orders for CR#4, the resident did not have an order for catheter care, and that caused catheter care not to appear on the MAR for documentation. She said that she was aware that CR#4 was to have a UA completed to determine if she had a UTI at the time of her discharge on [DATE]. She stated that she completed the discharge for the resident, and at the time of discharge the relative present asked if the sample had been collected. She stated that when she told the relative that she would need to check, they declined to wait, and she did not follow up. She stated that the risk of not having the system in place is that a resident may not receive appropriate care and would be at risk for an UTI. She said that the IDT should meet to ensure that the admission process is completed with accuracy for newly admitted residents, but she was not sure if the IDT meet regarding CR#4. In an interview on [DATE] at 5:16pm with the Admin #2, he said that the DON is clinical oversite, and she should inform him of any clinical concerns. He said that the admitting nurse should enter orders upon admission. He said that he had not had a chance to look of admitting process since starting his position on [DATE]. He said that he was aware that CR#4 did not have a UA collected as ordered by the physician, as he spoke with relative after the resident discharged who inquired about the result. He said that he had a nurse whose name he could not remember to lock up the result, and he was told that the sample was not collected, and he relayed the information to the relative. He said that it would be concerning if a resident did not have physician orders, care plan, or MAR, or progress notes in place for catheter. He said that if a tasks is not documented it did not happen. He said that the risk of not having the system in place could cause a resident to not to receive proper care that could cause an infection or UTI. In a follow-up interview and observation on [DATE] at 5:40 pm with LVN B, she said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that baseline care plans are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that CR#4 was admitted with a catheter, it was removed, she could not remember the date of removal, or the staff that removed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 11 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0690 Level of Harm - Actual harm Residents Affected - Few it. She said that she completed catheter care for CR#4, and she documented the tasks in the EMR. She said that on [DATE] CR#4 LVN A told her that the NP ordered a UA to test for a UTI and asked her to collect the sample. She said that the lab collects samples on Tuesday and Thursday unless the orders are stat. She said that she could not remember if she collected the sample before the resident discharged , or if she notified the physician. She reviewed the physician order summary report, baseline care plan, progress notes, lab summary report, and MAR for CR#4. She said that she could not remember what orders were being used when providing catheter care. She said that the based on the documents the UA sample was not collect and there was no documentation that CR#4 received catheter care. She said that the admitting nurse LVND did not enter the orders for catheter and the baseline care plan did not address catheter care for CR#4. She said that the risk to CR#4 was having an untreated infection when she discharged charge, and without having orders, MAR, and care plan to address catheter care the resident could not have received appropriate care while the catheter was in place. In an interview on [DATE] at 10:41am with LVN C, she said that she has worked at the facility since [DATE], and she works the 6am-6pm shift. She said that the admitting nurse is responsible for completing the admission observation, admission progress notes, entering the physician orders, and baseline care plan for newly admitted residents. She said that baseline care plans are completed by the ADON. She said that the ADON or CCM check to make sure the admission process for newly admitted residents were completed accurately. She said that if a resident is admitted with a catheter the admitting nurse should entering the standard order for catheter, and that would trigger the care on the MAR. She said that she provided care for CR#4 while she was admitted to the facility, and the resident admitted with a catheter. She said that she provided catheter care to resident. She said that the NP gave an order to remove the catheter on approximately [DATE] in the 11:00am hour, and she removed the catheter. She said that the NP ordered that urine output be monitored for 3-6 hours after the catheter was removed and be notified if the resident had no urine output. She stated that when she removed the catheter CR#4 had urine output of 400cc in the catheter bag, and the resident voided her bladder in her brief sometime in the afternoon. She stated that she entered a progress note on the date that she removed the catheter, and she would have documented catheter care on the MAR in the EMR. She reviewed the physician order summary report, baseline care plan, progress notes, and MAR for CR#4. She said that the admitting nursing, LVN D, did not enter the standard order upon admission so catheter care for CR#4 was not on the MAR, and did not complete the baseline care plan time, and when it was competed it did not include catheter care. She said that she could not remember what orders were being used when providing catheter care. She said that all staff that provided catheter should have saw the error when it was time to chart and corrected the error. She said that the risk of not having physician orders, baseline care plan, and MAR in place is that a CR#4 may have not received care to the catheter, and without care the resident could have developed an UTI. She said that based on the progress notes there was concern that CR#4 had signs of UTI and the NP requested urine sample collected. She said that if the sample was not collected and the NP was not notified the resident was at risk of being discharged with an untreated infection that could caused the resident to be hospitalized . In an interview on [DATE] at 1:42pm with LVN D, she said that she only worked at the facility for a short period of time, and her last day would have been the week of [DATE]. She said that the admitting nurse is usually responsible for entering physician orders for newly admitted residents. She said that she could not remember if she provided care for CR#4, and she did not feel comfortable with answering any more questions. In a phone interview on [DATE] at 2:00pm with NP, he said that he was familiar with CR#4, and she admitted to the facility with a catheter from a local (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 12 of 13 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 675222 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seabreeze Nursing and Rehabilitation 6602 Memorial Dr Texas City, TX 77590 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 0690 Level of Harm - Actual harm Residents Affected - Few hospital after having a stroke and fall prior to admission. He said that he was not sure of what orders CR#4 had for catheter care upon admission, but the facility uses a standard order unless hospital discharge summary provided an order. He said that he gave an order for CR#4 to have the catheter removed on [DATE]. He said that staff notified him that resident was having behaviors on [DATE], and he ordered a UA as he wanted to confirm if the resident had a UTI before referring for a psychiatry consult. He said that the lab usually because of samples on Tuesday and Thursday, and he would have expected that the sample would have been collected and sent to the lab on [DATE]. He said that when he saw the resident on [DATE] the facility had not collected the sample. He said that he was not notified that there were problems with completing the lab after the order was given. He said that if the staff was having problems with collecting the sample, he should have been notified, and he could have given an order to collect the urine sample by straight cath (used for quick drainage of the bladder). He said that CR#4 was transferred on [DATE] to another facility. He said that since the physician he practiced under services the facility CR#4 transferred to, he updated his progress notes, and notified the receiving facility to collect the sample upon admission. He said that he is not the nurse practitioner for the facility that CR#4 transferred to, but he made the nurse practitioner aware of his concerns for UTI. He said resident labs confirmed a UTI, but he was not sure what treatment was given. Record review of the facility policy and procedure entitled Catheter Care, Urinary dated 2018 read in part, .Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Preparation: 1. Review the residents care plan to assess for any special needs of the resident. Input/Output: 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Documentation: The following information may be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) given the catheter care. 3. All assessment data obtained when giving catheter care FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 13 of 13