Inspection·January 13, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .Retacrit Injection Solution 4000 UNIT/ML (Epoetin Alfa-epbx) Inject 4000 unit subcutaneously at bedtime every Mon, Wed, Fri related to END STAGE RENAL DISEASE .-D/C Date-01/10/2023 2:19. The administration time of 9:00 pm had the number 9 and unknown initials documented on 1/6/23, 1/8/23 and 1/9/23. Per TAR chart codes, the number 9=Other/See Progress Notes. There were no corresponding progress notes regarding Retacrit Injection Solution 4000 UNIT/ML on 1/6/23, 1/8/23 or 1/9/23. Further record review of Resident #127's TAR revealed that on 1/7/23 for the administration time of 9:00 pm the number 15 and unknown initials were documented and per the TAR chart codes, the number 15=Med Hold. Interview with the DON on 01/10/2023 at 1:12 pm regarding Resident #127's TAR and missing documentation regarding whether Resident #127's Retacrit Injection Solution 4000 UNIT/ML had been given. When asked why the TAR had the number 9 and initials on 1/6/23, 1/8/23 and 1/9/23, she said she did not know. When asked why there were no progress notes regarding the administration of Resident #127's Retacrit Injection Solution 4000 UNIT/ML, she said she did not know. When asked why Resident #127's TAR had the number 15 and unknown initials on 1/7/23, she said she did not know. The DON said she was not sure of what was going on with Resident #127's Retacrit medication and did not know what had happened. The DON said that she would try to find out if Resident #127 ever received the medication as ordered and try to clarify the actual physician order for the medication. Record review of Resident #127's Physician Order Summary Report for January 2023 revealed the following: . Retacrit Injection Solution 4000 UNIT/ML (Epoetin Alfa-epbx) Inject 4000 unit subcutaneously at bedtime related to END STAGE RENAL DISEASE . Communication Method .Prescriber Written . Order Status .Active . Order Date .01/05/2023 . Start Date 01/06/2023. Further record review of Resident #127's Physician Order Summary Report for January, 2023 continued with the following orders: .Retacrit Injection Solution 4000 UNIT/ML (Epoetin Alfa-epbx) Inject 4000 unit subcutaneously at bedtime every Mon, Wed, Fri related to END STAGE RENAL DISEASE .give if hemaglobin is below ten otherwise hold .Communication Method .Phone .Order Status .Active .Order Date 01/10/2023 .Start Date .01/11/2023. Observation and interview with RN B on 1/10/23 at 1:22 pm at the medication cart for Resident #127 who said that Resident #127's Retacrit medication was not on the cart or in the refrigerator. RN B said that the DON had just come by and checked the cart and refrigerator. RN B said that she had received a call from the pharmacy yesterday, (1/9/23), asking for clarification of the Retacrit Injection Solution 4000 UNIT/ML because it had originally been ordered to be given daily at bedtime. RN B said that the order had been clarified now and the order changed to every Monday, Wednesday and Friday which were also Resident #127's outpatient dialysis days. When asked if she documented any of this information, RN B said that the DON had just instructed her to complete a late entry note. When asked if Resident #127 had ever received the medication since her admission on [DATE], she said she did not know because the medication was ordered for bedtime and would have been given on the evening shift, but that it did not look like she had, because the medication was not in the facility. She also said that if a medication was a high cost, it would require authorization from the DON. She said she did not know if there had been any such authorization. In a follow up interview with the DON on 1/10/23 at 1:32 pm the DON said that RN B would be completing a late entry progress note/documentation clarifying the new order as of today (1/10/23) for Resident #127's Retacrit Injection Solution 4000 UNIT/ML every M, W and F. The DON said that the order had been clarified yesterday and that RN B had not documented for some reason. The DON said that the information should have been documented at the time of the order. The DON also said that the clinical staff found out yesterday (1/9/23) that the Dialysis center wanted the facility to give the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675323 If continuation sheet Page 2 of 8 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 675323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Retacrit instead of the Dialysis center giving it. The DON said that the Reatcrit was part of Resident #127's admission orders and that as far as she could tell, the resident had not received the medication since admission. The DON said that in speaking with Resident #127's Physician A, the resident had lab work completed on 1/6/23 and was not anemic, and therefore, had not suffered any acute harm as a result of not receiving the medication since admission. The DON said that new admission orders should be reconciled at the time of admission by the nurse admitting the resident. Record review of Resident #127's Progress Notes revealed the following entry by RN B: Effective Date: 01/10/2023 1:04 pm Type: General Nurses Note Note Text: Late entry for yesterday 1/9/23. (sic) Sn called MD to clarify order for retacrit per pharmacy request. Per MD give retacrit on dialysis days Monday, Wednesday Friday. (sic) SN updated order and called dialysis center to ensure patient would not get double doses (sic) of this medication. Per dialysis nurse facility (sic) SN to administer Retacrit per MD order. Record review of Resident #127's Progress Notes revealed the following entry by DON: Effective Date: 01/10/2023 1:20 pm Type Alert Note Note Text: Call placed to pharmacy to inquire why Retacrit prescription has not been filled and delivered. Pharmacist shared dispensed on 1/9/23. Pharmacist shared medication would be delivered if Hgb greater than 10. Hgb on 1/6/23 was 11.1 therefore pharmacy did not send medication. Physician A notified and clarification orders received for medication along with lab orders. Record review of Resident #127's lab results revealed resident had blood work completed on 1/5/23 that revealed a Hemoglobin (Hgb) result of 11.1. Normal Hemoglobin range is 12.1 to 15.1 for females. Requested a copy of facility policy and procedure on medication administration from the DON on 1/10/23 at 4:33 pm and again on 1/12/23 at 10:50 am and did not receive prior to survey exit. Record review of untitled and undated facility document read in part: .Once you receive the medication list, you will have to verify the medications with our admitting physician .Remember these medications will have to be verified by second nurse once they are entered .that is the only way they can be released. Record review of facility policy and procedure Charting and Documentation, Revised July 2017 revealed in part .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response.2. The following information is to be documented in the resident medical record: e. Events, incidents, or accidents involving the resident .3. Documentation in the medical record will be objective .complete and accurate .7. Documentation of procedures and treatments will include care-specific details, including c. the assessment data and/or any unusual findings .f. notification of family, physician, or other staff . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675323 If continuation sheet Page 3 of 8 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 675323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for food service safety, in that: -1 plastic container of expired food was present in the refrigerator. This failure could place residents at risk for cross-contamination and foodborne illnesses. Findings include: Observation of the kitchen on 01/11/2023 at 9:25am, revealed 1 turkey wrap in a clear plastic container dated 01/07/2023 with a use by date of 01/10/2023 in refrigerator. Interview and observation on 01/11/2023 at 9:37am with Dietary Aid A, she stated she had been employed at the facility for 6 years. She stated that the turkey wrap was made on 01/07/2023, and it she should have been thrown out after the use by date on 01/10/2023. She stated that staff check for expired food in the refrigerator twice daily before breakfast meal service and after dinner service. She stated that that the turkey wrap should have been thrown out on 01/10/23 after the dinner service, and she did not know why it had not been thrown out. She stated that the risk to residents of not removing expired food is foodborne illnesses. She was observed to remove the expired food from the refrigerator. Interview on 01/11/2023 at 9:49am with Dietitian/Dietary Manger, she stated that she was made aware that expired food was observed in the refrigerator. She stated that staff check for expired food in the refrigerator twice daily before breakfast meal service and after dinner service. She stated that the turkey wrap should have been thrown out. She stated that staff had been in-serviced on the topic. She agreed to provide a copy of the last in-service and the policy for discarding expired food items. Interview on 01/12/2023 at 10:44am with Dietitian/Dietary Manger, she stated that staff should be checking for outdated food and it should be thrown out. She stated that she did not know why staff did not check on 01/10/2023. She stated that the risk to residents of staff not checking for expired food items is food borne illness. She stated that there is not a policy that specifically detailed discarding expired food items, but staff have been trained on the procedure. She stated that the last in-service was on 09/12/2022-09/13/2022, and she provided a copy. Record review of the facilities Dietary In-Service dated 09/12/2022-09/13/2022 read in part, . make sure to check frig for items that are outdated and throw away or freeze to avoid waste. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675323 If continuation sheet Page 4 of 8 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 675323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Few -The facility failed to ensure the dumpster lids and doors were secured. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. Findings include: An observation on 1/11/23 at 9:26 am., revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial-sized dumpster with garbage inside of it. There were 2 lids on the dumpster, the right lid was open. Interview and observation on 1/11/23 at 9:26 am, with Dietary Aide A, she said that she did not know that the dumpster lids must always be closed, she said that she thought the regulation to do so would be to avoid infestation of pest. Interview on 1/11/23 at 9:50 am with the Dietary Manager/Dietician she said that the dumpsters outside are to be kept closed to prevent rodents, pests, and insects out of the dumpster and from entering the facility. She acknowledged that the dumpster lids must have been left opened by the last staff who used the dumpster. She stated it was the responsibility of all staff to ensure the lids were closed after using the dumpster. Record review of the facility policy and procedure entitled Food-Related Garbage and Rubbish Disposal. dated revised April 2006 read in part .all garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use .garbage and rubbish containing food wastes will be stored in a manner what is inaccessible to vermin. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675323 If continuation sheet Page 5 of 8 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 675323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573 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 observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident #127) reviewed for resident records, in that: -Resident #127's progress notes were not complete or accurate regarding her Retacrit medication. This deficient practice placed residents who receive medications from facility staff at risk for less than therapeutic benefits and/or not receiving ordered medications due to incomplete documentation. Findings include: Record review of Resident #127's admission record revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with end stage renal (kidney) disease (a condition in which a person's kidneys cease functioning on a permanent basis leading to the need for regular long-term dialysis or kidney transplant to maintain life), dialysis (a procedure to remove waste products and excessive fluid from the blood when the kidneys stop working), type II diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), peripheral vascular disease, (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), edema (swelling), heart failure (a chronic condition in which the heart does not pump blood well), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and open wound of abdominal wall (condition that can be caused by trauma or surgery). Record review of Resident #127's electronic medical record revealed only an entry MDS dated [DATE] which did not include a BIMS/SAMS assessment or ADL function assessment. Record review of Resident #127's TAR dated 1/1/2023-1/31/2023 on1/10/23 at 1:00 pm revealed the following entries: .Retacrit Injection Solution 4000 UNIT/ML (Epoetin Alfa-epbx) Inject 4000 unit subcutaneously at bedtime every Mon, Wed, Fri related to END STAGE RENAL DISEASE .-D/C Date-01/10/2023 2:19. The administration time of 9:00 pm had the number 9 and unknown initials documented on 1/6/23, 1/8/23 and 1/9/23. Per TAR chart codes, the number 9=Other/See Progress Notes. There were no corresponding progress notes regarding Retacrit Injection Solution 4000 UNIT/ML on 1/6/23, 1/8/23 or 1/9/23. Interview with the DON on 01/10/2023 at 1:12 pm regarding Resident #127's TAR and missing documentation regarding whether Resident #127's Retacrit Injection Solution 4000 UNIT/ML had been given. When asked why the TAR had the number 9=Other/See Progress Notes and unknown initials on 1/6/23, 1/8/23 and 1/9/23, she said she did not know. When asked why there were no progress notes regarding the administration of Resident #127's Retacrit Injection Solution 4000 UNIT/ML, she said she did not know. Observation and interview with RN B on 1/10/23 at 1:22 pm at the medication cart for Resident #127 who said that Resident #127's Retacrit medication was not on the cart or in the refrigerator. RN B said that the DON had just come by and checked the cart and refrigerator. RN B said that she had received a call from the pharmacy yesterday, (1/9/23), asking for clarification of the Retacrit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675323 If continuation sheet Page 6 of 8 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 675323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573 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 Injection Solution 4000 UNIT/ML because it had originally been ordered to be given daily at bedtime. RN B said that the order had been clarified now and the order changed to every Monday, Wednesday and Friday which was also Resident #127's outpatient dialysis days. When asked if she documented any of this information, RN B said that the DON had just instructed her to complete a late entry note. In a follow up interview with the DON on 1/10/23 at 1:32 pm the DON said that RN B would be completing a late entry progress note/documentation clarifying the new order as of today (1/10/23) for Resident #127's Retacrit Injection Solution 4000 UNIT/ML every M, W and F. The DON said that the order had been clarified yesterday and that RN B had not documented for some reason. The DON said that the information should have been documented at the time of the order. Record review of Resident #127's Progress Notes revealed the following entry by RN B: Effective Date: 01/10/2023 1:04 pm Type: General Nurses Note Note Text: Late entry for yesterday 1/9/23. (sic) Sn called MD to clarify order for retacrit per pharmacy request. Per MD give retacrit on dialysis days Monday, Wednesday Friday. (sic) SN updated order and called dialysis center to ensure patient would not get double doses (sic) of this medication. Per dialysis nurse facility (sic) SN to administer Retacrit per MD order. Record review of Resident #127's Progress Notes revealed the following entry by DON: Effective Date: 01/10/2023 1:20 pm Type Alert Note Note Text: Call placed to pharmacy to inquire why Retacrit prescription has not been filled and delivered. Pharmacist shared dispensed on 1/9/23. Pharmacist shared medication would be delivered if Hgb greater than 10. Hgb on 1/6/23 was 11.1 therefore pharmacy did not send medication. Physician A notified and clarification orders received for medication along with lab orders. Record review of untitled and undated facility document read in part: .Once you receive the medication list, you will have to verify the medications with our admitting physician .Remember these mediations will have to be verified by second nurse once they are entered .that is the only way they can be released. Record review of facility policy and procedure Charting ad Documentation, Revised July 2017 revealed in part .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response.2. The following information is to be documented in the resident medical record: e. Events, incidents, or accidents involving the resident .3. Documentation in the medical record will be objective .complete and accurate .7. Documentation of procedures and treatments will include care-specific details, including c. the assessment data and/or any unusual findings .f. notification of family, physician, or other staff . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675323 If continuation sheet Page 7 of 8 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 675323 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Baywind Village Skilled Nursing & Rehab 411 Alabama Ave League City, TX 77573 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #1 and #3) of 3 residents reviewed for infection control. Residents Affected - Some -CNA-A did not wash or sanitize her hands in between assisting multiple residents with feeding. This failure could place residents who required feeding assistance with cross contamination and infection. Findings include: Observation on 01/13/2023 at 12:39pm of CNA-A in the dining area assisting residents with feeding. CNA-A was observed moving from one resident's table to another resident's table to assist with feeding. CNA-A was not observed washing or sanitizing her hands in between assisting residents. Interview on 01/13/2023 with CNA-A at 2:27pm, she stated she has been employed at the facility for about 3-4 months and she was still in training. CNA-A stated hand hygiene was supposed to be performed before entering a resident's room and prior to assisting a resident with feeding. She stated hand hygiene was also supposed to be performed after providing resident care and before moving to another resident. She stated the staff were able to sanitize their hands 3 times before washing them with soap and water. She stated she did not perform hand hygiene in between assisting residents because she was busy, and she was just trying to get things done. She stated the risk of not completing hand hygiene could cause COVID, mixing germs and possible infections. Interview om 01/13/2023 with the DON at 2:44pm, she stated the staff are trained to wash their hands or use hand sanitizer in between providing resident care. She stated the staff are able to sanitize their hands 3 times in between washes before having to wash their hands again. She stated she was responsible for ensuring the staff completed hand hygiene and infection control. She stated the risk of not completing proper hand hygiene could cause infections and outbreaks. Record review of the facilities Handwashing/ Hand Hygiene policy dated April 2020 stated, Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after assisting a resident with meals. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675323 If continuation sheet Page 8 of 8