Inspection·November 5, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication error. During an interview on 11/29/25 at 5:01 p.m., the DON asked the ADON if she destroyed oxycodone for Resident #1. The ADON said she did not remember destroying any controlled pain medication for Resident #1 in September 2025 or October 2025.During an interview on 11/29/25 at 5:03 p.m., the DON stated that an agency nurse (LVN V) signed off the evening PRN control pain medication in the control book on 11/08/25 at 11:30 p.m., but did not sign on the TAR. The DON said it could imply the pain medication was not administered to Resident #1 on 11/08/25 at 11:35 p.m. because it was not signed on the TAR as administered. The DON said two nurses, or the aide, should have destroyed the medication, documented on the count sheet that the medication was destroyed, and signed off on the control count sheet. The DON said medication should be signed off on the control count sheet, and after the nurse or MA administered the medication, the nurse or MA should sign off on the MAR or TAR. The DON said it was a medication error because LVN V and RN E signed off the control pain medication on the count sheet, and LVN V and RN E did not sign on the MAR or TAR.During an interview on 11/05/25 at 8:49 a.m., the ADON said when LVN V and RN E signed off on control medication from the narcotic book, they should also sign off on the MAR or TAR after administering the medicine to Resident #1. She said that if LVN V and RN E did not sign off on the MAR or TAR after administration of the control pain medication, it meant the medication was not administered. She said Resident #1 could still be in pain. The ADON said two nurses or medication aides have to destroy any controlled medication, and both staff would sign off on the control book that the medication was destroyed.During a telephone interview on 11/05/25 at 10:01 a.m., MA L said scheduled control pain medications were kept in the medication aide cart, while the nurse kept the PRN control pain medication in the nurse's cart. MA L said RN E walked up to her in the medication room on 10/09/25 and said she was going to give Resident #1's control PRN pain medication. MA L told RN E she was going to administer Resident #1 his scheduled 8:00 a.m., scheduled control pain medication, and she had pouched out the medication. MA L said RN E told her to give her the medication, and she would administer the pain medicine to Resident #1, and she handed Resident #1's pain medication to RN E. She said that when medication was signed out on the control sheet, it should correspond with the MAR, and if it did not, it would indicate a medication error. MA L said she did not sign the MAR because the nurse gave the medication, and she did not know if RN E had already punched out the nurse's PRN medication. She said the nurse should have wasted one of the medications because she had two tablets of pain medication at the same time. MA L said when narcotics were wasted, two nurses should dispose of the medication, and both staff would sign off on the control sheet.During an interview on 11/05/25 at 10:38 a.m., RN E said she had already punched out the control PRN pain medication for Resident #1 before she told MA L she was going to give Resident #1 his PRN controlled pain medication. RN E said MA L gave her the scheduled 8:00 a.m. pain control medication for Resident #1 because both of them were about to administer the same pain medication at the same time. She said she wasted her PRN pain control medication in the pill bottle (drug buster), and she forgot to have a witness sign when she wasted the pain control medication or signed in the control book that the medication was wasted. RN E said anybody with untrained eyes would think she took the medication because she signed off the medication from the control book and did not sign on the MAR or TAR that she administered the pain medicine, and it looked like a drug deviation.During an attempted telephone interview on 11/05/25 at 11:04 a.m., the LVN V (agency nurse), who worked on 10/08/25 and signed off medication on the control book, but it was not signed off on the TAR, did not answer and the surveyor left a message. LVN V did not return the call.Record review of the facility policy and procedure, undated, titled Narcotic Count Before and After Shift, read in part, . Purpose: to ensure the accurate accountability, security, and proper handling of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675323 If continuation sheet Page 2 of 3 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 11/05/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete all controlled substances in the facility. This policy safeguards residents, staff, and the facility from medication errors, discrepancies, and potential diversion. procedure #5. Wasting narcotics. Wastage of any portion of a controlled substance must be: Witnessed by two licensed nurses. Documented on the Controlled Substance Record (including amount wasted, reason, date/time, and both nurses' signatures) .Record review of the facility policy on medication administration dated 2001 MED-PASS, Inc, revised April 2019, read in part, Medications are administered in a safe and timely manner, and as prescribed. policy interpretation and implementation #22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Event ID: Facility ID: 675323 If continuation sheet Page 3 of 3