Inspection·March 25, 2024

F 0684 *02/11/2024 not administered: resident unavailable by Nurse D. Level of Harm - Minimal harm or potential for actual harm * 02/28/2024 not administered: drug/item unavailable comment: prn wet to dry dressing applied through applied. by the Wound Care Nurse. Residents Affected - Few Record review of Wound Care Doctor's note revealed the following wound measurement: Site #1 surgical wound right abdomen full thickness 03/18/2024 = 19cm x 16cm x 2cm 03/11/2024 = 19.5cm x 16cm x 2cm 03/04/2024 = 28cm x 20cm x 3cm 02/29/2024 = 27cm x 20cm x 3cm 02/05/2024 = 27cm x 20cm x 3cm Site #2 surgical wound left upper abdomen full thickness. 03/18/2024 = 2cm x 1.5cm x 1.5cm 03/11/2024 = 2cm x 2cm x 2cm 03/04/2024 = 5cm x 4cm x 2cm 02/29/2024 = 6cm x 4cm x 2cm 02/05/2024 = 6cm x 4cm x 2cm Site #3 stage 3 pressure wound of the left buttock. 03/11/2024 = Resolved 03/04/2024 = 2cm x 2cm x 0.1cm 02/29/2024 = 2cm x 2cm x 0.1cm 02/05/2024 = 3cm x 3cm On 02/23/2024 at 11:36am in an interview with Resident #5 stated they were not treating her wound very well, they were not helping her to apply the wound vac to her wound. She said every time she went to the hospital her wound would be very close to healing but when she comes back to the facility they did not do much for her wound. Resident #5 said she barely gets wound care in a day at the facility, she said if she was in hospital they could do her wound up to 3 three times sometime if needed, but at the facility, they did not do her wound regularly and they did not put the wound vac on her. She said they have Wound Care Nurse at the building who does her wound vac but if the wound care nurse was not in the building nobody does her wound vac. She said the wound care doctor only came one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 2 of 26 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 03/25/2024 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 0684 time and when he came he watched the wound care nurse do the wound vac. Level of Harm - Minimal harm or potential for actual harm On 02/23/2024 at 11:36am observation revealed the wound vac was not connected to Resident #5's wound. Resident #5 stated the floor nurse last night (02/22/2024) who took care of her could not fix the wound vac, she said the nurse told her that she did not know how to fix Resident #5's wound vac. She said the nurse came in to dress her wound when her wound was saturated but she was unable to put the wound vac back on her because she could not do it, the nurse (Nurse B) had to do wet to dry dressing. Residents Affected - Few On 02/23/2024 at 12:26pm in an interview with Nurse A, she stated said she never had the opportunity to do Resident #5's wound because the Resident #5 was on B-bed, and the B-beds were assigned to the night-shift nurses while the A-beds were assigned to the day-shift nurses. She stated the facility had a wound care nurse who was taking care of residents' wound, and if the wound care nurse was not in the building, the wound dressing change of patients were done by the nurses. Nurse A stated she was aware Resident #5 had wounds and a surgical wound where the wound vac was to be applied. Nurse A stated she did not know if the wound vac was to be applied weekly and she had to go look it up. She stated she had not done a wound vac before, even though as a nurse she had been trained to do wound vac, but she did not have any training at the facility to do wound vac. She stated the wound care nurse was not in the facility today. On 03/04/2024 at 11:43am in an observation and interview with Resident #5, she stated she did not have any wound care yesterday Sunday 03/03/2024. She stated if the wound care nurse was not around, she would probably not get wound care. Surveyor observed the wound vac, and it was not connected to Resident #5's wound, the wound vac was on a table by the bedside. Resident stated she did not have the wound vac for many days when the wound care nurse was away. She stated the wound vac was placed by the Wound Care Nurse on the last weekend, the date on the canister revealed 2/29/2024. She said when the wound care nurse put the wound vac on her, it worked really well for about a day, but the wound vac canister was full and the wound vac stopped working and she believed that it was because the canister was full. She stated they disconnected the wound vac three days ago. She said all they needed to do was to empty it or change it and fix the wound vac back into her wound, but she did not know why they were not doing that. On 03/04/2024 at 11:56am in a wound observation with the Wound Care Nurse, the surgical wound on the right abdomen was observed covered in clean dressing dated today (03/04/2024) the nurse removed the dressing and Surveyor observed the surgical wound at resident's right abdomen - it appeared red beefy about the size 28cm x 20cm the left buttock pressure wound appeared red beefy and round, about 4cm x 4cm in size. There was no concern with the process of the wound care and infection control. The wound care nurse stated she did not apply the wound vac today because Resident #5 was on her way to hospital for blood transfusion because resident's lab came back with low blood level. On 03/04/2024 at 12:28pm in an interview with the Wound Care Nurse, she stated if she was not in the building, the nurses on the floor were responsible to do the wound, she was not aware that the nurses did not know how to operate the wound vac. The wound care nurse stated she was gone on vacation from Thursday 2/22/2024 till the Wednesday 2/28/2024. She did not know if they were doing the wound vac or placing the wet to dry on the resident. She said the wound vac keeps excess drainage from the wound because if the drainage was sitting in the wound dressing, it could grow bacteria and affect the wound the more, and could cause the wound to decline and the surrounding tissue could get damaged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 3 of 26 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 03/25/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/04/2024 at 12:51pm in an interview with Nurse A, she stated the floor nurses also did wound care for residents on weekends (Saturdays and Sundays) because the Wound Care Nurse' schedule was Monday to Friday and they did not have weekend wound care nurse. She stated if Resident #5's wound vac needed to be fixed or if anything happened she would not be able to apply the wound vac but she would do wet-to dry wound dressing. She stated she had not spoken with anyone in the past regarding her not able to apply wound vac, but she told the DON about the wound vac today 03/04/2024 and she (DON) said they would train the nurses and show them how to use it. She said generally, wound vac help to heal and control drainage so the wound can heal well. She stated they could do a wet-to-dry dressing if they were not able to do the wound vac. On 03/04/2024 at 2:57pm in an interview with the Attending Physician, she stated she saw Resident #5 few weeks ago within the week of her admission, and she had been taking care of Resident #5 for about a month. She stated she saw Resident #5's wound and saw the Wound Care Nurse did the wound vac on that day. The Attending Physician stated the wounds were severe and large and Resident #5 was in pain when she saw her. She said she could not handle the wound alone, especially any wound with a wound vac. She said when it comes to wound vac, you need to know what you are doing she would have a wound specialist consulted to follow the resident, which was why the wound care Doctor followed Resident #5 to ensure proper management and monitoring of her wounds. She stated she was not aware that nurses were not able to apply wound vac on the resident. The Attending Physician stated wound care was not her specialist, but she knew the wound vac was an integral part of the resident's care and the Wound Care Doctor knew better why the wound vac had to be used. On 3/5/2024 at 2:04pm in an interview with the Wound Care Doctor, he stated he had not been able to see the Resident #5 much, because the Resident #5 would go to dialysis Mondays Wednesdays and Fridays and sometimes she would be sent to hospital for non-wound related issue. The Wound Care Doctor said he came to the facility mostly on Mondays. He stated the wound vac was a very important as part of the care of Resident #5 because it was recommended by a specialist surgeon who did the surgery for her, and the wound vac would help residents wound to heal better. The Wound Care Doctor said compared to a wet to dry, the wound vac was recommended and more preferred by the specialist who recommended it, any he would not change that. He said there was order in place for wet to dry dressing change in case something happened to the wound vac. He said his expectation was that when orders were given, the order should be followed by the facility and the employees. He stated no one ever informed him that the floor nurses did not know how to apply wound vac for Resident #5. He said the order for wet-to-dry dressing change was given in case anything happened to the wound vac, there could be any accident, it could fall, it was a machine, and it could malfunction at any time, and that was why they gave the order for wet-to-dry dressing. The Wound Care Doctor stated but the main treatment for the wound was the wound vac according to the recommendation from the specialist surgeon. On 03/05/2024 at 4:34pm in an interview with the ADON, she stated Resident #5 was always refusing her wound vac and she was told by the Wound Care Nurse that Resident #5 was refusing her wound vac, so the wound care nurse did wet to dry dressing. She stated she assisted in supervising and overseeing the duties of other nurses and to make sure their jobs and the documentation were done properly. She stated no nurse ever told her that they were not able to do wound vac. She said they did not have any training on wound vac or wound care, she said the nurses get the training in nursing school and they all should be able to apply wound vac. She stated the wound vac was to aide in the healing process of wounds and it was used to remove the drainage from the wound so it would not become infected. On 03/05/2024 at 4:46pm in an interview with the Wound Care Nurse, she stated that Resident #5 did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 4 of 26 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 03/25/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm not refuse care or refuse wound vac for her. She stated she could not remember any day that the resident refused wound care or wound vac. She stated they would do wet to dry dressing for Resident #5's wound when going to dialysis on Mondays, Wednesdays, and Fridays. She was not sure if she selected the wrong reason for not doing the wound vac on 2/28/2024, that day was Wednesday and could be the resident was going for dialysis. Residents Affected - Few On 03/06/2024 at 9:37am in an interview with Nurse B, she stated she knew Resident #5 had abdominal wound, bottom wound, left abdominal wound and colostomy, she stated the facility Wound Care Nurse comes to the facility on Mondays to Fridays and the wound care nurse always did the wounds, while the floor nurses - dayshift nurses do A beds and the night shift do B beds whenever the Wound Care Nurse did not come to work. She said she had not been trained on the wound vac at the facility. Nurse B stated the resident did not have the wound vac functioning on the night of 2/22/24, the wound vac was attached but it was not working, and the dressing was due for the night. Nurse B stated she told the resident she did not know how to operate the wound vac and she would do the wet-to-dry dressing as in the order. She said the resident had never refused any care that she knew of. She stated the ADON was the supervisor who oversaw their work. She stated had not specifically told her supervisor she was not trained on wound vac but she was sure she must have mentioned it to them sometime. She said on 2/26/24 and 2/27/24 the wound vac was not on the resident at that time and she (Nurse B) did wet-to-dry dressing. On 03/05/2024 at 3:48pmin an interview with Nurse C stated she did not regularly work with Resident #5's . Nurse C stated she may have assisted the resident with her wound once but the wound vac was malfunctioning at that time so she did wet- to-dry. She stated she was not confident on how to apply wound vac and she had not received any training to do wound vac at the facility but she had been trained somewhere else. She stated she had not mastered using the wound vac to the point that she would be able to do it confidently. She stated she had not told her supervisor to do wound vac training for her. On 03/07/2024 at 2:22pm in an interview with Nurse D, she stated she worked night shift. She was usually the nurse taking care of Resident #5 every time she worked on that side of the facility hall. She stated she had not changed her wound vac before but have changed the canister for her wound vac in the past. She said she believe she was very competent to apply wound vac, she had done wound vac on another resident but had not applied wound vac on Resident #5 because Resident #5's wound vac was being done differently, and she was not able to do it. She stated on 2/23/2024 during the night shift she remembered she had to change Resident #5's wound dressing because it was saturated, and she changed the cannister but when she removed the dressing wound, she could not re-apply the wound vac, because she was not sure how to apply it properly, and she did not want to mess up anything. She stated she did wet to dry for that night on 2/23/2024. She stated Wound vac was useful for a wound with a lot of drainage because the wound vac removed body fluid drainage from the wound, she said if the drainage was not removed the wound would not heal and could be infected. On 03/06/2024 in an interview with the DON, she stated none of the nurses informed her that they were not able to apply wound vac on Resident #5. The DON stated the wound vac promote healing of the wound and prevent infection by removing excess drainage from the wound. She stated they had started in servicing the nurses and they would also have the wound vac company come in to train the nurses on using the wound vac and have each nurse perform a return demonstration. Facility policy titled 'Competency of Nursing Staff' dated May 2019 revealed in part . licensed nurses and nursing assistants employed or contracted by the facility will demonstrate specific (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 5 of 26 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 03/25/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm competency and skill sets deemed necessary to care for the needs of residents as identified through resident assessments and described in the plans of care. The facility did not have policy for quality of care or wound vac. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 6 of 26 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 03/25/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 4 of 17 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for smoking. 1. The facility failed to ensure Resident #1 had proper supervision after her smoke assessment stated she was careless with smoking materials and dropped ashes on herself. Her care plan stated she needed an extender and apron to be safe. She was observed without supervision, an apron or extender. 2. The facility failed to ensure Resident #2 had proper supervision after he was found smoking in his room located in the memory care unit. He was supposed to be supervised by his family member. His family member was not supervising him upon observation. 3. The facility failed to ensure Resident #3 had supervision after she was deemed non-compliant with smoking and had placed a half-smoked cigarette, she had just extinguished into a brown paper bag. 4. The facility failed to ensure Resident #4 was observed to be smoking without supervision when her smoking assessment stated she did not smoke. An immediate jeopardy (IJ) was identified on 2/29/2024 at 2:39 p.m. The IJ template was provided to the facility on 2/29/2024 at 3:01p.m. While the IJ was removed on 3/3/2024 at 11:22 a.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents who smoke and their roommates at risk of harm from burns or fires, explosions, hospitalization, and death. Findings Included: Resident #1 Record review of Resident #1's face sheet dated 2/28/2024 revealed she was a [AGE] year-old female who was admitted on [DATE]. She was diagnosed with anoxic brain damage(a brain injury due to restriction on the oxygen supplied to the brain), acute respiratory disease(a life-threatening lung injury that allows fluid to leak into lungs), muscle wasting and atrophy(is the decrease in size and wasting of muscle tissue), multiple sites; hereditary and idiopathic neuropathy(an illness where sensory and motor nerves of the peripheral nervous system are affected), unspecified; other lack of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 7 of 26 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 03/25/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some coordination, dysphagia oropharyngeal phase(problems with chewing and preparing food to be swallowed), bipolar disorder (mental disorder marked by extreme changes in mood, thought or behavior) and major depressive disorder (when an individual has persistently low or depressed mood). Record review of Resident 1's quarterly MDS dated [DATE] revealed C0500- BIM summary score was 04, which represented severe cognitive impairment. Section GG Functional abilities and goals had upper extremities such as shoulder, elbow, wrist, and hand were coded (1)- which meant Impairment on one side. Record review of smoking assessment dated [DATE] revealed she was careless with smoking materials-Drop cigarette butts/matches on the floor, furniture, self or others; smoked near oxygen. Coded at (3)- severe problem. Further review revealed the smoking risk at bottom of form stated she was scored at 6follow facility policy. Scores of 0-9 was deemed safe to smoke. Record review of smoking assessment dated [DATE] revealed she was to use a smoke apron for safety & extender provided to help promote functional ability when smoking with supervision. Record review of care plan dated 1/10/2024 and updated 2/28/2024 stated Resident #1 has smoking extender provided during smoking to hold and ash cigarettes. Observation of Resident #1 on 2/28/2024 at 9:52am revealed she was smoking a cigarette in the smoking area. Resident #1 was observed without supervision, extender or apron to be safe while smoking. Resident #2 Record review of Resident #2's face sheet dated 2/28/2024 revealed he was a [AGE] year-old male who was admitted on [DATE]. He was diagnosed with unspecified intercranial injury without loss of consciousness (a brain injury without losing consciousness), need for assistance with personal care, unspecified injury at C6 level of cervical spinal cord (an injury with paralysis from the chest down, in hands and partially in the wrists), conversion disorder with seizures or convulsion( a condition in which a person experiences physical and sensory problems), schizoaffective disorder a mental health disorder including schizophrenia and mood disorder), dementia (group of thinking and social symptoms that interferes with daily functioning), shortness of breath, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and cognitive communication deficit(problems speaking, hearing, understanding, reading and writing). Record review of Resident #2's quarterly MDS dated [DATE] revealed C0500 was scored at 09 represented moderately impaired. Record review of Resident #2's smoke assessment dated [DATE] revealed it was safe for him to smoke. His smoking risk was 0. A score of 0-9 was deemed a safe smoker. No supervision was deemed necessary. Record review of Resident #2's care plan dated 2/14/2024 read in part: Problem: I am a smoker; I must be supervised. I have smoked in my room. Intervention: Smoking paraphernalia will be kept by nursing and activity department. Observation of Resident #2 on 2/28/2024 at 9:52am revealed he was smoking a brown cigarette without staff supervision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 8 of 26 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 03/25/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An interview with the ADON on 2/28/2024 at 10:01am, she stated the residents are independent smokers. She said they are allowed to keep cigarettes and lighters on their person as this was their home. She stated Resident #2 was the only resident must have supervision. She stated he only smokes when his RP was there to supervise him. She said otherwise he does not smoke. She was informed Resident #2's RP was not observed in the designated smoking area with him, and he was smoking a cigarette. The ADON stated Resident #2's RP arrived earlier in the morning and must have stepped away from him briefly. She said all other residents can smoke when they want and do not require staff supervision. An interview with Resident #2's RP on 2/28/2024 at 12:37pm, revealed she usually take Resident #2 out of the memory care unit to smoke. She said she visit him at least 3 to 4 times per week. She said she was approached by the ADON, who told her she was not supposed to leave Resident #2 unsupervised. She said she apologized and did not want any trouble for Resident #2. She said she usually do not leave his side. She did not say where she was when he was observed unsupervised this morning at 9:52am. She said he had smoked in his room once and she made sure she takes all cigarettes and lighters with her when she leaves the facility. She said she could understand how that could be dangerous because he was in the memory care due to both short and long-term memory loss and wandering. She said and another memory care resident might wander into his room and get a hold of his cigarettes. She said she understands the facility concern. An interview with MA A on 2/28/2024 at 12:53pm, revealed she mostly work on the secured memory care unit. She said Resident #2's RP took him out to smoke. She said he does not understand English very well and have memory impairment. She said Resident #2's RP usually stayed with him while he smoked and walk him back to the memory care unit. She said she was not sure why she was not with him upon my observation. She said she observed her walking him out to the designated smoking area this morning around 9:30am. She said she had heard Resident #2 smoked in his room recently. She said this was dangerous because most of the residents are wanderers. If they were to get a hold of cigarettes and lighters, this could be dangerous for the entire facility. Resident #2 was observed to be smoking unsupervised on 2/28/2024 at 9:52am. Resident #2 was supposed to be supervised by his family member but was not being supervised upon observation. Resident #3 Record review of Resident #3's face sheet dated 2/28/2024 revealed she was a 62- year-old female that was admitted to the facility on [DATE]. She had diagnosed with unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), paranoid schizophrenia(is a mental disorder characterized by reoccurring episodes of psychosis), cognitive communication deficit (difficulty thinking and how someone uses language), and dysphagia(difficulty or discomfort in swallowing). Record review of Resident #3's smoke assessment dated [DATE] revealed it was safe for her to smoke. She had a score of 0. A score of 0-9 were deemed a safe smoker. Record review of Resident #3 MDS dated [DATE] revealed BIMS summary score was 14 which represented cognitively intact. Record review of Resident #3's care plan dated 5/26/2023 and edited on 12/19/2023 read in part: Problem: I am not compliant with smoking policy. Goal: I will smoke only during smoke times. Approach: I will be monitored to only smoke in designated smoking areas and times or might lose my privileges. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 9 of 26 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 03/25/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety This care plan did not match the smoking assessment which revealed she was a safe smoker with a score of 0. A score of 0-9 were deemed a safe smoker. Observation of Resident #3 on 2/28/2024 at 9:52am, revealed she was smoking a cigarette without staff supervision. Further observation revealed Resident #3 left the smoke area and went inside to the lobby area. She had placed her half-smoked cigarette and a lighter inside a brown paper bag. Residents Affected - Some Resident #4 Record review of Resident #4 face sheet dated 2/28/2024 revealed she was a [AGE] year-old female. She was diagnosed with: Chronic obstructive pulmonary disease(a group of lung disease that block air flow and causes difficulty in breathing), acute or chronic diastolic congestive heart failure (left ventricle muscle becomes stiff or thickened), pneumonia(infection that flames air sacs in one or both lungs, which may fill with fluid) unspecified, Sepsis unspecified organism(a life-threatening complication of an infection), acute upper respiratory infection, muscle wasting and atrophy(the decrease in size and wasting of muscle tissue), and bipolar disorder (episodes of mood swings ranging from depressive lows and manic highs) Record review of smoke assessment dated [DATE] revealed description: Resident quit smoking. Smoking assessment- Does resident smoke? No, was checked. Record review of care plan dated 2/29/2024 revealed a Problem start date: 2/29/2024 Category: Smoking: Resident #4 wants to smoke. I am a smoker. I require the following supervision. Goal: I will safely smoke in designated area(s) at scheduled times through next review. I will be assisted with smoking cessation as applicable. The care plan did not match the smoking assessment which stated she was not a smoker. Observation of Resident #4 on 2/28/2024 at 9:52am revealed she was sitting in her wheelchair smoking a cigarette without staff supervision. Further observation on 2/28/2024 at 3:28 p.m. revealed her to be sitting in her wheelchair in her room. There was an oxygen tank inside of her room. An interview with Resident #4 on 2/28/2024 at 3:28pm, she stated that she has been a smoker for over 50 years. She said she has never attempted to stop smoking. She said she enjoyed smoking and found it difficult to get through the day without smoking. She denied smoking in her bedroom. She stated she had her cigarettes and lighter in a plastic bag. She pointed to the plastic bag that was on her end table. She stated the facility smoke policy has changed numerous times. She said at one point they wanted to keep all cigarettes and lighters. She said that did not work because all smokers wanted to keep their own. She said she can keep all of her smoking paraphernalia on her person. She said she understand some residents that smoke might need supervision. She said she does not require supervision as she has her faculties and quite capable of keeping her own smoking paraphernalia. An interview with the traveling DON on 2/28/2024 at 10:06a.m., revealed she has been working at the facility for about 5-6 weeks. She said she had taken the brown paper bag from Resident #3. She said inside of the bag was a half-smoked cigarette and a lighter. She said she took it from Resident #3 because it could have caused a fire. She stated she believed the Activity Assistant was supervising the residents who were outside smoking. She was informed no staff was supervising the four residents observed to be smoking. She said the company smoke policy was in the process of being changed to keeping all resident's paraphernalia in locked boxes and they would be kept at the nursing station. She said trying to change this procedure/policy has been met with a lot of pushbacks from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 10 of 26 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 03/25/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents as they have rights. She said they are waiting for lockboxes to be delivered and all residents cigarettes and smoke devices will be locked. She said not keeping residents' paraphernalia made her a little uneasy because she knows what can happen. She said unsafe smoking habits of one resident could cause a disaster for the entire facility. She denied any of the residents of this facility smoked near oxygen. She denied any residents smoked in their room. An interview with the Administrator on 2/28/2024 at 10:17a.m., revealed residents are allowed to smoke safely without supervision. They can have cigarettes and lighters in their rooms. However, they are transitioning to lockboxes to store cigarettes mostly due to complaints about cigarettes being stolen. He denied any unsafe smoking habits by the four residents observed outside smoking without supervision. He denied residents had smoked inside their rooms. He stated no staff had to provide supervision and that was why no one was supervising the resident as they smoked today (2/28/2024). He was informed the care plans and smoking assessments for the residents did not contain the same information. He said he would have his nurses investigate the discrepancies. He provided the facility smoking policy, smoke times and a census of all smokers. An interview with the Activity Assistant on 2/28/2024 at 10:55 a.m., she said she was not scheduled to supervise the residents smoking, but she would have helped, if asked by management. She said residents can keep their smoking items on their person and they do not have to be supervised, as far as she was aware. She said all the residents observed smoking today (2/28/2024) were capable of smoking unsupervised. An interview with an anonymous staff on 2/28/2024 at 1:17pm revealed Resident #2 has smoked in his room about 1 month ago. He was not a safe smoker and should not have cigarettes or lighters in his room. The anonymous staff stated Resident #4 also smoked in her room recently and uses oxygen. Residents are allowed to keep cigarettes and lighters in their rooms. The anonymous staff stated this was very unsafe and have voiced this concern to the Administrator. The anonymous staff stated the smoking policy has changed multiple times. At one point, staff were told the residents were not allowed to keep cigarettes on their person. They were supposed to turn in to the nursing station. The anonymous staff also stated the residents smoked at any time they wanted including some that go out late at night. An interview with ADON on 2/28/2024 at 2:08pm, revealed the residents that are deemed to be safe smokers can keep their cigarettes and lighters with them and do not require supervision as this is their home. She said only Resident #1 required a smoking extender utensil to catch the cigarette ashes due to her dexterity issues. She said the facility had purchased a cigarette extender for Resident #1 to use. The ADON was informed Resident #1 was not observed with an extender today (2/28/2024 at 9:52 a.m.) and Resident #2's RP was not observed to be supervising him. She said Resident #2's RP must have stepped away for a minute. She was not sure why his RP did not stay with him the whole time. She was not sure why Resident #1 was not using her extender at the time. An interview with SW on 2/29/2024 at 12:22pm, revealed she has been employed for 1 year. She said the facility is in the process of changing their smoking policy. She said currently residents can keep their cigarettes and lighters, but they will be keeping all smoking paraphernalia in lock boxes when they are delivered. She said staff are not currently supervising smoking. She stated that she is not responsible for smoking assessments. She said the MDS nurse/ ADON does the smoking assessments. She said 2 residents that will need supervision is Residents #1 and #2. She said Resident #1 has an extension stick that is used to dump her ashes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 11 of 26 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 03/25/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety An interview with HR on 2/29/2024 at 12:36pm, she stated residents can currently smoke independently. She said the facility will be changing the policy soon to have all smokers supervised. She said she is responsible for new admissions. She stated the admission packet she provided was the facility's most current packet given to new residents and included their smoking policy. Record review of the facility's smoking census revealed there were 17 residents listed. Residents Affected - Some Record review of the facility's smoke schedule updated on 2/1/2024 were as follow: 8:30 am- Maintenance Director 11am- Laundry/Housekeeping 1:00pm- North Hall nurse or designee 3:00pm- South Hall Nurse or designee 6:30pm- North Hall nurse or designee 8:00pm- South Hall nurse or designee At the bottom of smoking schedule, it stated smokers are to be observed for safety and until the last cigarette is extinguished and smoking materials are all locked up. No residents are allowed to keep smoking materials or have keys to lock boxes. Violations of policies will result in suspension & potential termination of smoking privileges. Record review of smoking policy dated 10/2023 read in part: This facility shall establish and maintain safe resident smoking practices. 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The resident will be evaluated on admission to determine if he or she is a safe smoker or non-smoker. If a smoker, the evaluation will include current level, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision. 11. Any residents with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possessions. Only disposable safety lighters are permitted. All other forms of lighters and matches are prohibited. Record review of an undated facility admission packet Attachment K-smoking read in part: Our facility provides our residents and our employees with a smoke-free environment. While we recognize the need of many of our residents and employees to work and live in a smoke-free environment, we must also respect the rights of those residents and employees who choose to smoke. 2. Residents and Visitors -Certain smoking restrictions apply to our residents and visitors. 19.7.4 (2). This facility will supervise all resident smoking for the safety of all residents and employees. Supervised smoking times for residents are scheduled and limited to 15-minute increments. All resident smoking paraphernalia must be checked in with the nurse. Resident smoking paraphernalia will be secured at the nurse's station and provided to the resident at specified smoking times. An immediate jeopardy (IJ) was identified on 2/29/2024 at 2:39 p.m. The Administrator and traveling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 12 of 26 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 03/25/2024 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 0689 DON were notified. The Administrator was provided with the IJ template on 2/29/2024 at 3:01p.m. A Plan of Removal was requested at that time. Level of Harm - Immediate jeopardy to resident health or safety The following Plan of Removal submitted by the facility was accepted on 02/29/2024 at 4:58pm. and included: Residents Affected - Some 2 /29/2024 - F689 Immediate Actions: Identification Action: All smoking residents will be reassessed. Observations to be completed in the medical records. Residents' care plans will match the residents' smoking assessments. Person(s) Responsible: Assistant Director of Nursing, Clinical Case Manager (MDS Coordinator), Clinical Resource Nurse, and/or Designee Date Completed: 2/29/2024 by 5PM Immediate/Prevention Action: All smoking residents will be educated on the facility's smoking policy , which has been changed to supervised smoking, with emphasis on smoking paraphernalia shall not be on their persons and smoking must be supervised by assigned staff. Person(s) Responsible: Social Services, Assistant Director of Nursing, and/or Designee Date Completed: 2/29/2024 by 5:30PM Immediate/Prevention Action: All staff educated over the facility's smoking policy, (which has been changed to supervised smoking, with emphasis on smoking paraphernalia shall not be on their persons and smoking must be supervised by assigned staff), reporting smoking non-compliance to the administrator, and intervening with residents that are noted smoking with no supervision (immediately begin supervising the resident(s) smoking). Assigned staff/smoking schedule (times the staff are responsible for smoking supervision)- staff will know to communicate with coworkers if unable to fulfill scheduled monitoring time and an alternate staff member will fill in. During routine nursing/CNA rounds, room cleanings (housekeeping), department head Angel Rounds staff will know to check for signs of unauthorized smoking via smell and visually checking for smoking paraphernalia being out/butts being in the trash cans, and the actual act of the residents smoking. All staff will be educated prior to working their next shift. All new/temporary (agency) staff will be educated prior to working their first/next shift. Person(s) Responsible: Administrator and/or Designee Date Completed: 3/1/2024 by 10AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 13 of 26 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 03/25/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Immediate/Prevention Action: Sign posted on the entrance doors to read, All smoking paraphernalia will be taken to the nurses' station, residents are not to have any cigarettes, lighters, and electronic smoking devices/vapes. Person(s) Responsible: Administrator and/or Designee Date Completed: 2/29/2024 by 5PM Immediate/Prevention Action: Binder of residents needing interventions while smoking (such as a smoking apron) will be placed outside each smoking area for staff reference to ensure residents interventions are in place while smoking. Smoking schedule/Assignments will be posted by binder. There are 4 smoking aprons on-site and are only required for residents that are assessed and deemed necessary to utilize the apron for safety. Person(s) Responsible: Administrator and/or Designee Date Completed: 2/29/2024 by 6:30PM Immediate/Monitor Action: Administrative Personnel and/or Designees will monitor/observe smoking areas, at minimum, twice daily, x4 weeks, to ensure safe smoking practices. Any residents noted to be non-compliant with the smoking policy will be re-educated. At this time the monitor will check for binder placement and ensure the intervention list is updated (see above action item). Monitors will be educated regarding their roles prior to observing. Person(s) Responsible: Administrator and/or Designee Date Completed: 2/29/2024 by 630PM Immediate/Monitor Action: At minimum, each occupied room will be checked once, daily, x4 weeks and as needed for signs of unauthorized smoking (through smell and visual checks-see education action above). Monitors will be educated regarding their roles prior to observing. Person(s) Responsible: Administrator and/or Designee Date Completed: 3/1/2024 by 11AM QAPI Action: Ad Hoc QAPI performed with Medical Director informing him of the IJ template and Seabreeze's plan to remove the immediacy. Person(s) Responsible: Administrator and/or Designee Date Completed: 2/29/2024 by 630PM Monitoring of the plan of removal from 3/3/2024 to 3/6/2024 included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 14 of 26 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 03/25/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Observation on 3/1/2024 at 10:00 a.m. revealed a sign on the entrance door that read, All smoking paraphernalia will be taken to the nurses' station, residents are not to have any cigarettes, lighters, and electronic smoking devices/vapes. Observation on 3/1/2024 at 11:05 a.m. of 2 white smoke aprons located in a cabinet in the designated smoking area for Resident #1 to use for ash droppings. Residents Affected - Some Observation on 3/1/2024 at 1:10 p.m., revealed Resident #1 was wearing a smoking apron and supervision by staff. Observation on 3/2/2024 at 11:10am, staff was observed to be supervising the residents as they smoked. Interviews with Residents who smoked began on 3/1/2024 at 12:47 p.m. Residents #4, #15, #16, #17, #18 all were able to state the new policy in which staff are to supervise all residents. Cigarettes, lighters, chewing tobacco and vapes are to be kept at the nursing stations and all smoke times were to be adhered to. Interviews with Regional Nurse Consultant on 3/1/2024 at 10:32 a.m., revealed a room sweep had been conducted on 2/29/2024 and all cigarettes, lighters, vapes, and chewing tobacco was confiscated and placed in Ziplock bags with the residents' names on them and inside a locked box kept at the nursing station or medication room. She said she was still putting the binder together with all the updated smoking assessments. Interviews with CNA's B and F, Housekeeping Supervisor, Housekeepers A and B, LVN E, LVN F and RN A between 3/1/2024 at 9:35 a.m.- 3/2/2024 at 1:30 p.m., were able to explain the new policy in which staff are to supervise all residents that smoked, all paraphernalia was kept in locked boxes, and no residents are to keep cigarettes and lighters in their rooms or on their personal. An interview with the Regional Nurse Consultant on 3/3/2024 at 10:30 a.m., she stated the ADON texted all staff and had everyone come in for the mandatory training concerning smoking on 2/29/2024. She said all training was completed for staff prior to working a shift. She said all rooms have been checked at least once daily, a written notice that a telephone call was placed informed the Medical Director of the IJ template and the facility's plan to remove the immediacy. An interview with MDS Nurse on 3/5/2024 at 3:21p.m., revealed Resident #1 is doing well with the use of the apron. She said Resident #1 has dexterity concerns and have already had therapy to try to improve. She is not capable of holding cigarettes properly. She stated that she was responsible for the updated smoking assessments and care plans. She stated Resident #2 was the only resident that required supervision because of his memory loss. She stated that she was not sure why the care plans did not match the smoking assessments. She added that the policy had changed a few times and that might be why. She said she and the ADON were both responsible for the smoking assessments and care plans. Record review for smoking assessments for 21 residents were completed and had updated care plans. Record review of the updated smoking policy provided on 3/1/2024 revealed in part: This facility shall establish and maintain safe resident smoking practices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 15 of 26 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 03/25/2024 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 0689 9. All residents shall have direct supervision of a staff member while smoking. Level of Harm - Immediate jeopardy to resident health or safety 11. All residents smoking paraphernalia must be checked in with the nurse. 12. Resident smoking paraphernalia will be stored in a secure location and provided to the resident at specified smoking times. Residents Affected - Some Record review of the new smoking contract dated 2/29/2024 revealed 19 residents had signed the new smoking contract. According to census, two residents were in the hospital. The Administrator did not return to the facility after 2/29/2024. Therefore, no further interviews took place concerning the facility admission packet which stated that the facility was a smoke-free facility. The Regional Nurse Consultant was informed the Immediate Jeopardy was removed on 3/3/24 at 11:22 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 16 of 26 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 03/25/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care and the facility failed to provide care which included but not limited to assessing, evaluating, planning and implementing resident care plans and responded to resident needs for 1 (Resident #5) of 3 residents reviewed for wound care. In that, The facility failed to ensure Resident #5's wound vac was applied on her wound as ordered by the physician. This deficient practice could place residents at-risk for improper care practices, infection, injury, and hospitalization. Findings included: Record review of Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of diabetes mellitus (metabolic disease, involving inappropriately elevated blood glucose levels), chronic pain, Essential (primary) hypertension (too high pressure in the blood vessel), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm.), cardiac arrhythmia (a disease process characterized by when electrical impulses in the heart don't work properly), congestive heart failure (occurs when the heart's capacity to pump blood cannot keep up with the body's need), constipation. Record review of Resident #5's care plan dated 02/24/2024 revealed Resident #5 had surgical wounds with intervention to apply negative pressure at setting of (125) mm Hg continuous. Record review of Resident #5's MDS (Minimum Data Set) dated 02/24/2024 revealed Resident #5 had surgical wounds. Record review of Resident #5's order dated 02/01/2024 revealed order was given for wound treatment NPWT (KCI): Wound location (RUQ/ABD). Cleanse wound with wound cleanser, pat dry, apply foam to wound bed, cover with transparent dressing. Apply Negative Pressure at setting of (125) mm Hg (continuous). Change dressing/tubing/canister 2x weekly on M/F, once a day on Mon, Fri Resident #5 also had order for PRN (as needed) wound care dressing change for the wound to be cleansed with wound cleanser, and apply gauze soaked in Dakin's 0.25% solution to be applied on the wound and cover with dressing. Record review of TAR (Treatment Administration Record) for the month of February 2024 revealed the wound vac was not applied on the following dates: *02/11/2024 not administered: resident unavailable by Nurse D. * 02/28/2024 not administered: drug/item unavailable comment: prn wet to dry dressing applied through applied. by the Wound Care Nurse. Record review of Wound Care Doctor's note revealed the following wound measurement: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 17 of 26 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 03/25/2024 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 0726 Site #1 surgical wound right abdomen full thickness Level of Harm - Minimal harm or potential for actual harm 03/18/2024 = 19cm x 16cm x 2cm 03/11/2024 = 19.5cm x 16cm x 2cm Residents Affected - Few 03/04/2024 = 28cm x 20cm x 3cm 02/29/2024 = 27cm x 20cm x 3cm 02/05/2024 = 27cm x 20cm x 3cm Site #2 surgical wound left upper abdomen full thickness. 03/18/2024 = 2cm x 1.5cm x 1.5cm 03/11/2024 = 2cm x 2cm x 2cm 03/04/2024 = 5cm x 4cm x 2cm 02/29/2024 = 6cm x 4cm x 2cm 02/05/2024 = 6cm x 4cm x 2cm Site #3 stage 3 pressure wound of the left buttock. 03/11/2024 = Resolved 03/04/2024 = 2cm x 2cm x 0.1cm 02/29/2024 = 2cm x 2cm x 0.1cm 02/05/2024 = 3cm x 3cm On 02/23/2024 at 11:36am in an interview with Resident #5 stated they were not treating her wound very well, they were not helping her to apply the wound vac to her wound. She said every time she went to the hospital her wound would be very close to healing but when she comes back to the facility they did not do much for her wound. Resident #5 said she barely gets wound care in a day at the facility, she said if she was in hospital they could do her wound up to 3 three times sometime if needed, but at the facility, they did not do her wound regularly and they did not put the wound vac on her. She said they have Wound Care Nurse at the building who does her wound vac but if the wound care nurse was not in the building nobody does her wound vac. She said the wound care doctor only came one time and when he came he watched the wound care nurse do the wound vac. On 02/23/2024 at 11:36am observation revealed the wound vac was not connected to Resident #5's wound. Resident #5 stated the floor nurse last night (02/22/2024) who took care of her could not fix the wound vac, she said the nurse told her that she did not know how to fix Resident #5's wound vac. She said the nurse came in to dress her wound when her wound was saturated but she was unable to put the wound vac back on her because she could not do it, the nurse (Nurse B) had to do wet to dry (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 18 of 26 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 03/25/2024 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 0726 dressing. Level of Harm - Minimal harm or potential for actual harm On 02/23/2024 at 12:26pm in an interview with Nurse A, she stated said she never had the opportunity to do Resident #5's wound because the Resident #5 was on B-bed, and the B-beds were assigned to the night-shift nurses while the A-beds were assigned to the day-shift nurses. She stated the facility had a wound care nurse who was taking care of residents' wound, and if the wound care nurse was not in the building, the wound dressing change of patients were done by the nurses. Nurse A stated she was aware Resident #5 had wounds and a surgical wound where the wound vac was to be applied. Nurse A stated she did not know if the wound vac was to be applied weekly and she had to go look it up. She stated she had not done a wound vac before, even though as a nurse she had been trained to do wound vac, but she did not have any training at the facility to do wound vac. She stated the wound care nurse was not in the facility today. Residents Affected - Few On 03/04/2024 at 11:43am in an observation and interview with Resident #5, she stated she did not have any wound care yesterday Sunday 03/03/2024. She stated if the wound care nurse was not around, she would probably not get wound care. Surveyor observed the wound vac, and it was not connected to Resident #5's wound, the wound vac was on a table by the bedside. Resident stated she did not have the wound vac for many days when the wound care nurse was away. She stated the wound vac was placed by the Wound Care Nurse on the last weekend, the date on the canister revealed 2/29/2024. She said when the wound care nurse put the wound vac on her, it worked really well for about a day, but the wound vac canister was full and the wound vac stopped working and she believed that it was because the canister was full. She stated they disconnected the wound vac three days ago. She said all they needed to do was to empty it or change it and fix the wound vac back into her wound, but she did not know why they were not doing that. On 03/04/2024 at 11:56am in a wound observation with the Wound Care Nurse, the surgical wound on the right abdomen was observed covered in clean dressing dated today (03/04/2024) the nurse removed the dressing and Surveyor observed the surgical wound at resident's right abdomen - it appeared red beefy about the size 28cm x 20cm the left buttock pressure wound appeared red beefy and round, about 4cm x 4cm in size. There was no concern with the process of the wound care and infection control. The wound care nurse stated she did not apply the wound vac today because Resident #5 was on her way to hospital for blood transfusion because resident's lab came back with low blood level. On 03/04/2024 at 12:28pm in an interview with the Wound Care Nurse, she stated if she was not in the building, the nurses on the floor were responsible to do the wound, she was not aware that the nurses did not know how to operate the wound vac. The wound care nurse stated she was gone on vacation from Thursday 2/22/2024 till the Wednesday 2/28/2024. She did not know if they were doing the wound vac or placing the wet to dry on the resident. She said the wound vac keeps excess drainage from the wound because if the drainage was sitting in the wound dressing, it could grow bacteria and affect the wound the more, and could cause the wound to decline and the surrounding tissue could get damaged. On 03/04/2024 at 12:51pm in an interview with Nurse A, she stated the floor nurses also did wound care for residents on weekends (Saturdays and Sundays) because the Wound Care Nurse' schedule was Monday to Friday and they did not have weekend wound care nurse. She stated if Resident #5's wound vac needed to be fixed or if anything happened she would not be able to apply the wound vac but she would do wet-to dry wound dressing. She stated she had not spoken with anyone in the past regarding her not able to apply wound vac, but she told the DON about the wound vac today 03/04/2024 and she (DON) said they would train the nurses and show them how to use it. She said generally, wound vac help to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 19 of 26 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 03/25/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few heal and control drainage so the wound can heal well. She stated they could do a wet-to-dry dressing if they were not able to do the wound vac. On 03/04/2024 at 2:57pm in an interview with the Attending Physician, she stated she saw Resident #5 few weeks ago within the week of her admission, and she had been taking care of Resident #5 for about a month. She stated she saw Resident #5's wound and saw the Wound Care Nurse did the wound vac on that day. The Attending Physician stated the wounds were severe and large and Resident #5 was in pain when she saw her. She said she could not handle the wound alone, especially any wound with a wound vac. She said when it comes to wound vac, you need to know what you are doing she would have a wound specialist consulted to follow the resident, which was why the wound care Doctor followed Resident #5 to ensure proper management and monitoring of her wounds. She stated she was not aware that nurses were not able to apply wound vac on the resident. The Attending Physician stated wound care was not her specialist, but she knew the wound vac was an integral part of the resident's care and the Wound Care Doctor knew better why the wound vac had to be used. On 3/5/2024 at 2:04pm in an interview with the Wound Care Doctor, he stated he had not been able to see the Resident #5 much, because the Resident #5 would go to dialysis Mondays Wednesdays and Fridays and sometimes she would be sent to hospital for non-wound related issue. The Wound Care Doctor said he came to the facility mostly on Mondays. He stated the wound vac was a very important as part of the care of Resident #5 because it was recommended by a specialist surgeon who did the surgery for her, and the wound vac would help residents wound to heal better. The Wound Care Doctor said compared to a wet to dry, the wound vac was recommended and more preferred by the specialist who recommended it, any he would not change that. He said there was order in place for wet to dry dressing change in case something happened to the wound vac. He said his expectation was that when orders were given, the order should be followed by the facility and the employees. He stated no one ever informed him that the floor nurses did not know how to apply wound vac for Resident #5. He said the order for wet-to-dry dressing change was given in case anything happened to the wound vac, there could be any accident, it could fall, it was a machine, and it could malfunction at any time, and that was why they gave the order for wet-to-dry dressing. The Wound Care Doctor stated but the main treatment for the wound was the wound vac according to the recommendation from the specialist surgeon. On 03/05/2024 at 4:34pm in an interview with the ADON, she stated Resident #5 was always refusing her wound vac and she was told by the Wound Care Nurse that Resident #5 was refusing her wound vac, so the wound care nurse did wet to dry dressing. She stated she assisted in supervising and overseeing the duties of other nurses and to make sure their jobs and the documentation were done properly. She stated no nurse ever told her that they were not able to do wound vac. She said they did not have any training on wound vac or wound care, she said the nurses get the training in nursing school and they all should be able to apply wound vac. She stated the wound vac was to aide in the healing process of wounds and it was used to remove the drainage from the wound so it would not become infected. On 03/05/2024 at 4:46pm in an interview with the Wound Care Nurse, she stated that Resident #5 did not refuse care or refuse wound vac for her. She stated she could not remember any day that the resident refused wound care or wound vac. She stated they would do wet to dry dressing for Resident #5's wound when going to dialysis on Mondays, Wednesdays, and Fridays. She was not sure if she selected the wrong reason for not doing the wound vac on 2/28/2024, that day was Wednesday and could be the resident was going for dialysis. On 03/06/2024 at 9:37am in an interview with Nurse B, she stated she knew Resident #5 had abdominal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 20 of 26 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 03/25/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound, bottom wound, left abdominal wound and colostomy, she stated the facility Wound Care Nurse comes to the facility on Mondays to Fridays and the wound care nurse always did the wounds, while the floor nurses - dayshift nurses do A beds and the night shift do B beds whenever the Wound Care Nurse did not come to work. She said she had not been trained on the wound vac at the facility. Nurse B stated the resident did not have the wound vac functioning on the night of 2/22/24, the wound vac was attached but it was not working, and the dressing was due for the night. Nurse B stated she told the resident she did not know how to operate the wound vac and she would do the wet-to-dry dressing as in the order. She said the resident had never refused any care that she knew of. She stated the ADON was the supervisor who oversaw their work. She stated had not specifically told her supervisor she was not trained on wound vac but she was sure she must have mentioned it to them sometime. She said on 2/26/24 and 2/27/24 the wound vac was not on the resident at that time and she (Nurse B) did wet-to-dry dressing. On 03/05/2024 at 3:48pmin an interview with Nurse C stated she did not regularly work with Resident #5's . Nurse C stated she may have assisted the resident with her wound once but the wound vac was malfunctioning at that time so she did wet- to-dry. She stated she was not confident on how to apply wound vac and she had not received any training to do wound vac at the facility but she had been trained somewhere else. She stated she had not mastered using the wound vac to the point that she would be able to do it confidently. She stated she had not told her supervisor to do wound vac training for her. On 03/07/2024 at 2:22pm in an interview with Nurse D, she stated she worked night shift. She was usually the nurse taking care of Resident #5 every time she worked on that side of the facility hall. She stated she had not changed her wound vac before but have changed the canister for her wound vac in the past. She said she believe she was very competent to apply wound vac, she had done wound vac on another resident but had not applied wound vac on Resident #5 because Resident #5's wound vac was being done differently, and she was not able to do it. She stated on 2/23/2024 during the night shift she remembered she had to change Resident #5's wound dressing because it was saturated, and she changed the cannister but when she removed the dressing wound, she could not re-apply the wound vac, because she was not sure how to apply it properly, and she did not want to mess up anything. She stated she did wet to dry for that night on 2/23/2024. She stated Wound vac was useful for a wound with a lot of drainage because the wound vac removed body fluid drainage from the wound, she said if the drainage was not removed the wound would not heal and could be infected. On 03/06/2024 in an interview with the DON, she stated none of the nurses informed her that they were not able to apply wound vac on Resident #5. The DON stated the wound vac promote healing of the wound and prevent infection by removing excess drainage from the wound. She stated they had started in servicing the nurses and they would also have the wound vac company come in to train the nurses on using the wound vac and have each nurse perform a return demonstration. Facility policy titled 'Competency of Nursing Staff' dated May 2019 revealed in part . licensed nurses and nursing assistants employed or contracted by the facility will demonstrate specific competency and skill sets deemed necessary to care for the needs of residents as identified through resident assessments and described in the plans of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 21 of 26 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 03/25/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical record in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #8) reviewed for medical records, in that: Facility failed to ensure Resident #8's list of medication during discharge was kept in the medical record with the facility. This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication and delay in services. Findings include: Record review of facesheet revealed Resident #8 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), multiple sclerosis (immune-mediated disease that affects the nerve cells of the body), hemiplegia (paralysis that affects only one side of your body.), Parkinson's disease (progressive disease marked by tremor, muscle rigidity, slow imprecise movement, mostly affecting middle-aged and elderly people), pneumonia (an infection that occurs in the lungs when it is filled with fluid or pus). On 03/22/2024 at 1:46pm in an interview with Nurse E who discharged Resident #8, she stated when she discharged Resident #8, she wrote the list of all the medication sent home and signed the list. She kept a copy of the record in the medical record box and kept the other copy on the nurses station at the north side of the building. Nurse E stated she could not find the medication list when surveyor requested for it. On 03/22/2024 at 4:22pm in an interview with the Director of Nursing (DON) stated the medical record person quit some days ago and they had paperwork that was piling up and sometimes she (DON) tried to scan those documents whenever she came across them, but they were in the process of getting somebody into that position to continue to handle residents' records. She said it could be that somebody picked it and thought it was not an important document, and just put it somewhere. The DON said she started an in-service on Wednesday, 3/20/2024, about handling resident medical records, because she noticed some inconsistencies about how the resident information paperwork were being handled, and she wanted to put everything right because medical records are very important documents used for resident's care. The DON stated the MDS nurse was the one currently helping out with medical records. On 3/25/2024 at 12:09pm in an interview with the MDS Nurse stated she saw the Resident #8's discharge medication list at the north nursing station on Monday (03/11/2024) but she did not take it. She stated at the time she saw it, she was looking for another resident's medical record. The policy (Electronic Medical Records) provided did not address deficiency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 22 of 26 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 03/25/2024 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 0926 Have policies on smoking. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their own established smoking policy for 3 of 21 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance. Residents Affected - Some 1. The facility failed to effectively intervene or follow their own smoking policy when Resident #1 was known to drop cigarette ashes on herself. 2. The facility failed to implement their own policy when resident #2, a memory care resident had smoked in his room. 3. The facility failed to implement their own policy when Resident #3 was known to be non-compliant and placed a half-smoked cigarette that she had just extinguished into a paper bag. These failures placed smoking residents at risk for injury from burns and fires caused by hazardous smoking behaviors. Findings Included: Record review of Resident #1's face sheet dated 2/28/2024 revealed she was a [AGE] year-old female who was admitted on [DATE]. She was diagnosed with anoxic brain damage(a brain injury due to restriction on the oxygen supplied to the brain), acute respiratory disease(a life-threatening lung injury that allows fluid to leak into lungs), muscle wasting and atrophy(is the decrease in size and wasting of muscle tissue), multiple sites; hereditary and idiopathic neuropathy(an illness where sensory and motor nerves of the peripheral nervous system are affected), unspecified; other lack of coordination, dysphagia oropharyngeal phase(problems with chewing and preparing food to be swallowed), bipolar disorder (mental disorder marked by extreme changes in mood, thought or behavior) and major depressive disorder . Record review of Resident 1's quarterly MDS dated [DATE] revealed C0500- BIM summary score was 04, which represented severe cognitive impairment. Section GG Functional abilities and goals had upper extremities such as shoulder, elbow, wrist, and hand were coded (1)- which meant Impairment on one side. Record review of smoking assessment dated [DATE] revealed she was careless with smoking materials-Drop cigarette butts/matches on the floor, furniture, self or others; smoked near oxygen. Coded at (3)- severe problem. However, smoking risk at bottom of form stated she was scored at 6- follow facility policy. Scores of 0-9 was deemed safe to smoke. Record review of smoking assessment dated [DATE] revealed she was to use a smoke apron for safety & extender provided to help promote functional ability when smoking with supervision. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 23 of 26 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 03/25/2024 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 0926 Level of Harm - Immediate jeopardy to resident health or safety Record review of care plan dated 1/10/2024 and updated 2/28/2024 stated Resident #1 has smoking extender provided during smoking to hold and ash cigarettes. Observation of Resident #1 on 2/28/2024 at 9:52 a.m. revealed she was smoking a cigarette in the smoking area with Resident #2, Resident #3 and Resident #4 without staff supervision or an assistive device to catch the cigarette ashes. Residents Affected - Some Resident #2 Record review of Resident #2's face sheet dated 2/28/2024 revealed he was a [AGE] year-old male who was admitted on [DATE]. He was diagnosed with unspecified intercranial injury without loss of consciousness, need for assistance with personal care, unspecified injury at C6 level of cervical spinal cord, conversion disorder with seizures or convulsion, schizoaffective disorder, dementia, shortness of breath and peripheral vascular disease and cognitive communication deficit. Record review of Resident #2's quarterly MDS dated [DATE] revealed C0500 was scored at 09 represented moderately impaired. Record review of Resident #2's smoke assessment dated [DATE] revealed it was safe for him to smoke. His smoking risk was 0. A score of 0-9 was deemed a safe smoker. No supervision was deemed necessary. Record review of Resident #2's care plan dated 2/14/2024 read in part: Problem: I am a smoker; I must be supervised. I have smoked in my room. Intervention: Smoking paraphernalia will be kept by nursing and activity department. Observation of Resident #2 on 2/28/2024 at 9:52am revealed he was smoking a brown cigarette without staff supervision. Resident #3 Record review of Resident #3's face sheet dated 2/28/2024 revealed she was a 62- year-old female that was admitted to the facility on [DATE]. She had diagnosed with unspecified dementia, paranoid schizophrenia, Type 2 diabetes, cognitive communication deficit, dysphagia, presence of a cardiac pacemaker and atherosclerotic heart disease. Record review of Resident #3's smoke assessment dated [DATE] revealed it was safe for her to smoke. She had a score of 0. A score of 0-9 were deemed a safe smoker. Record review of Resident #3's care plan dated 5/26/2023 and edited on 12/19/2023 read in part: Problem: I am not compliant with smoking policy. Goal: I will smoke only during smoke times. Approach: I will be monitored to only smoke in designated smoking areas and times or might lose my privileges. Observation of Resident #3 on 2/28/2024 at 9:52 a.m., revealed she was smoking a cigarette without staff supervision. Further observation revealed Resident #3 left the smoke area and went inside to the lobby area. She had placed her half-smoked cigarette and a lighter inside a brown paper bag. An interview with the ADON on 2/28/2024 at 10:01a.m., she stated the residents are independent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 24 of 26 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 03/25/2024 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 0926 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some smokers. She said they are allowed to keep cigarettes and lighters on their person as this is their home. She stated Resident #2 is the only resident must have supervision. She stated he only smokes when his RP is there to supervise him. She stated that their policy would soon be changed, and all smokers would be supervised. An interview with the traveling DON on 2/28/2024 at 10:06 a.m., revealed she had been working at the facility for about 5-6 weeks She said the company smoke policy is in the process of being changed. All of the residents' paraphernalia would be kept in locked boxes and would be kept at the nursing station. She said trying to change this procedure/policy has been met with a lot of pushbacks from the residents as they have rights. She said they are waiting for lockboxes to be delivered and all residents cigarettes and smoke devices will be locked. She said unsafe smoking habits of one resident could cause a disaster for the entire facility. An interview with the Administrator on 2/28/2024 at 10:17a.m., revealed him to state for clarity, residents are allowed to smoke safely without supervision. They can have cigarettes and lighters in their rooms. However, they are transitioning to lockboxes to store cigarettes mostly due to complaints about cigarettes being stolen. He denied any unsafe smoking habits by the four residents observed outside smoking without supervision. He said the facility would be changing their policy to all smokers having supervision. He provided the facility smoking policy, smoke times and a census of all smokers. Record review of the facility's smoking census revealed there were 17 residents listed. Record review of the facility's smoke schedule updated on 2/1/2024 were as follow: 8:30 am- Maintenance Director 11am- Laundry/Housekeeping 1:00pm- North Hall nurse or designee 3:00pm- South Hall Nurse or designee 6:30pm- North Hall nurse or designee 8:00pm- South Hall nurse or designee At the bottom of smoking schedule, it stated smokers are to be observed for safety and until the last cigarette is extinguished and smoking materials are all locked up. No residents are allowed to keep smoking materials or have keys to lock boxes. Violations of policies will result in suspension & potential termination of smoking privileges. Record review of the facility's smoking policy dated April 2023 read in part: This facility shall establish and maintain safe resident smoking practices. 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The resident will be evaluated on admission to determine if he or she is a safe smoker or non-smoker. If a smoker, the evaluation will include current level, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision. 11. Any residents with restricted smoking privileges (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675222 If continuation sheet Page 25 of 26 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 03/25/2024 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 0926 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possessions. Only disposable safety lighters are permitted. All other forms of lighters and matches are prohibited. Record review of an undated facility admission packet Attachment K-Smoking read in part: Our facility provides our residents and our employees with a smoke-free environment. While we recognize the need of many of our residents and employees to work and live in a smoke-free environment, we must also respect the rights if those residents and employees who choose to smoke. 2. Residents and Visitors -Certain smoking restrictions apply to our residents and visitors. 19.7.4 (2). This facility will supervise all resident smoking for the safety of all residents and employees. Supervised smoking times for residents are scheduled and limited to 15-minute increments. All resident smoking paraphernalia must be checked in with the nurse. Resident smoking paraphernalia will be secured at the nurse's station and provided to the resident at specified smoking times. Event ID: Facility ID: 675222 If continuation sheet Page 26 of 26