Inspection·October 4, 2023

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity and respect for 1 of 9 (Resident #1) residents observed for dignity in that: -The facility failed to have a privacy curtain in Resident #1's room during wound dressing change. This failure could affect resident (s) that required assistance with care at risk for embarrassment and lower self-esteem. Findings: Record review of Resident #1's face sheet revealed an 83year old male admitted to the NF on 04/25/2023 with the following diagnoses: acute cystitis (inflammation of the bladder) without hematuria (blood in urine), obesity, hypertension (high blood pressure), atherosclerosis (build up cholesterol/fat in the artery causing obstruction of blood), coronary artery bypass, pneumonia (infection in the lung), gastro-esophageal reflux disease (acid from the stomach that backs up in the throat), and low back pain. Record review of Resident #1's MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating cognition level intact. Further review revealed that resident required extensive assistance with bed mobility, dressing, and toileting. Further review revealed that Resident #1 had 1 unhealed pressure ulcer. Record review of Resident #'s Physician Orders -dated 04/26/2023, indicated Venelex external ointment (alsam [NAME]-castor oil) apply to sacrum topically everyday shift for wound healing cleanse stage 2 to sacrum with NS (normal saline) or WC (wound cleanser). Pat dry, apply venelex and cover with a foam dressing. Change daily and PRN soiling. Record review of Resident #1's Care Plan dated 04/26/2023 revealed that resident was being care planned for stage 2 pressure ulcer of the sacrum. Observation on 05/06/2023 at 1:03p.m. Resident #1 was resting in bed on a regular mattress. Resident #1 was alert and oriented wearing oxygen via nasal cannula. Resident #1 bed was by the door. Resident #1's roommate was resting quietly in bed with eyes closed. LVN A entered room with dressing change supplies. Further observation was made of Resident #1 not having a privacy curtain. LVN A proceeded to change Resident #1's dressing to the sacral region with the assistance of CNA B. Both LVN A and CNA B repositioned Resident #1 in bed and began to change resident soiled linen on his bed. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 675323 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 10/04/2023 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)